Provider Demographics
NPI:1114657228
Name:GOUTERMOUT, SAMANTHA (NP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GOUTERMOUT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2507
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5921
Practice Address - Street 1:522 S 4TH ST
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-2946
Practice Address - Country:US
Practice Address - Phone:315-592-3930
Practice Address - Fax:315-592-3932
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717095363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner