Provider Demographics
NPI:1245417492
Name:GOBOURNE, PAUL A (CRNP)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:A
Last Name:GOBOURNE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1748 PORTAL DR NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1116
Mailing Address - Country:US
Mailing Address - Phone:202-722-7786
Mailing Address - Fax:202-722-1123
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:BLDG. 8 RM 3169C
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-5600
Practice Address - Country:US
Practice Address - Phone:301-400-1012
Practice Address - Fax:301-295-8963
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-29
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN965066363LF0000X
MDR132556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC035904300Medicaid
Q14873Medicare UPIN
DC035904300Medicaid