Provider Demographics
NPI:1245223429
Name:GOTTSHALL, STEVEN CLARK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:CLARK
Last Name:GOTTSHALL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 DAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9302
Mailing Address - Country:US
Mailing Address - Phone:304-647-4411
Mailing Address - Fax:
Practice Address - Street 1:1320 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:RONCEVERTE
Practice Address - State:WV
Practice Address - Zip Code:24970-8016
Practice Address - Country:US
Practice Address - Phone:336-716-5599
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59802367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2600666Medicare ID - Type Unspecified
VAQ37072AMedicare PIN
PA015898E4UMedicare ID - Type Unspecified