Provider Demographics
NPI:1225083082
Name:GOSSMAN, MARY JEAN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JEAN
Last Name:GOSSMAN
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18808 NW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-7599
Mailing Address - Country:US
Mailing Address - Phone:386-418-0111
Mailing Address - Fax:
Practice Address - Street 1:105 NW SANTA FE BLVD
Practice Address - Street 2:HIGH SPRINGS MEDICAL CENTER
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32655
Practice Address - Country:US
Practice Address - Phone:386-454-7746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL00000340OtherFLORIDA PRESCRIBING #
FL290008400Medicaid
FLPA1809OtherFL LICENSE #
FLPA1809OtherFL LICENSE #
FL290008400Medicaid