Provider Demographics
NPI:1083927057
Name:GOOCH, JERRY ALLEN
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ALLEN
Last Name:GOOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RT 1 BOX 569
Mailing Address - Street 2:
Mailing Address - City:CASHION
Mailing Address - State:OK
Mailing Address - Zip Code:73016
Mailing Address - Country:US
Mailing Address - Phone:405-795-3779
Mailing Address - Fax:
Practice Address - Street 1:921 NE 13TH ST.
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5028
Practice Address - Country:US
Practice Address - Phone:405-795-3779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64744367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered