Provider Demographics
NPI:1003586454
Name:GOETZ, GARY EDWIN (RN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWIN
Last Name:GOETZ
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HUNTER LN
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2499
Mailing Address - Country:US
Mailing Address - Phone:800-748-3243
Mailing Address - Fax:
Practice Address - Street 1:30 HUNTER LN
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2499
Practice Address - Country:US
Practice Address - Phone:800-748-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN952443632355A2700X
CA95244362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No2355A2700XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistAudiology Assistant