Provider Demographics
NPI:1316196298
Name:GOOLSBY, KIRSTEN MCKOY (PAC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:MCKOY
Last Name:GOOLSBY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:LAFAYE
Other - Last Name:MCKOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1701 WESTCHESTER DRIVE
Mailing Address - Street 2:SUITE 850
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-7254
Mailing Address - Country:US
Mailing Address - Phone:336-802-2400
Mailing Address - Fax:336-802-2534
Practice Address - Street 1:4515 PREMIER DR
Practice Address - Street 2:SUITE 203
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8357
Practice Address - Country:US
Practice Address - Phone:336-802-2200
Practice Address - Fax:336-802-2201
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01491363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759255Medicare PIN