Provider Demographics
NPI:1164041018
Name:GOSUK, ROSE ANN
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:ANN
Last Name:GOSUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH NAKNEK
Mailing Address - State:AK
Mailing Address - Zip Code:99670
Mailing Address - Country:US
Mailing Address - Phone:907-246-6546
Mailing Address - Fax:
Practice Address - Street 1:49 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOUTH NAKNEK
Practice Address - State:AK
Practice Address - Zip Code:99670
Practice Address - Country:US
Practice Address - Phone:907-246-6546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK20-1610-I172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker