Provider Demographics
NPI:1285816314
Name:GOLD COAST PULMONARY AND SLEEP ASSOC
Entity Type:Organization
Organization Name:GOLD COAST PULMONARY AND SLEEP ASSOC
Other - Org Name:NURSE PRACTITIONER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILCOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-443-0305
Mailing Address - Street 1:492 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4615
Mailing Address - Country:US
Mailing Address - Phone:860-443-0305
Mailing Address - Fax:860-444-0823
Practice Address - Street 1:492 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4615
Practice Address - Country:US
Practice Address - Phone:860-443-0305
Practice Address - Fax:860-444-0823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001296363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02829Medicare PIN