Provider Demographics
NPI:1093716995
Name:GOUGH, MICHELE LYNN (NP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:GOUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LYNN
Other - Last Name:LYTLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5777 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4502
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:5777 E MAYO BLVD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85054-4502
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2160363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ955875Medicaid
AZP00223804OtherRAILROAD MEDICARE
AZWCSKQOtherSUN HEALTH GROUP #
AZWCSKQOtherSUN HEALTH GROUP #
AZP00223804OtherRAILROAD MEDICARE
AZP66108Medicare UPIN