Provider Demographics
NPI:1306824446
Name:GOSAR, GRACE MARIE (MD)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:MARIE
Last Name:GOSAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 WEST LOTT
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:WY
Mailing Address - Zip Code:82834-1609
Mailing Address - Country:US
Mailing Address - Phone:307-684-2228
Mailing Address - Fax:307-684-2177
Practice Address - Street 1:497 W LOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:WY
Practice Address - Zip Code:82834-1609
Practice Address - Country:US
Practice Address - Phone:307-684-2228
Practice Address - Fax:307-684-2177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5314A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY307024OtherBLUE CROSS
WY307025OtherBLUE CROSS
F61294Medicare UPIN
WY307025OtherBLUE CROSS
WYW307024Medicare ID - Type Unspecified