Provider Demographics
NPI:1346274164
Name:GOEHRING, JERALD DEAN (PA)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:DEAN
Last Name:GOEHRING
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:JEROLD
Other - Middle Name:DEAN
Other - Last Name:GOEHRING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:500 WINDERLEY PL STE 115
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7406
Mailing Address - Country:US
Mailing Address - Phone:407-875-0555
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:407-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC804430Medicare PIN
COR76354Medicare UPIN