Provider Demographics
NPI:1346729696
Name:GOSS, BROOKLYNNE F (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKLYNNE
Middle Name:F
Last Name:GOSS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BROOKLYNNE
Other - Middle Name:BRIANA ASHLEY
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 NW 12TH AVENUE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:BATTLE GROUND
Mailing Address - State:WA
Mailing Address - Zip Code:98604
Mailing Address - Country:US
Mailing Address - Phone:360-723-0528
Mailing Address - Fax:360-995-0081
Practice Address - Street 1:101 NW 12TH AVENUE
Practice Address - Street 2:SUITE 107
Practice Address - City:BATTLE GROUND
Practice Address - State:WA
Practice Address - Zip Code:98604
Practice Address - Country:US
Practice Address - Phone:360-723-0528
Practice Address - Fax:360-995-0081
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-08
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA61058272363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2161801Medicaid