Provider Demographics
NPI:1407055742
Name:SAN JUAN HEALTHCARE PC
Entity Type:Organization
Organization Name:SAN JUAN HEALTHCARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BURK
Authorized Official - Last Name:GOSSOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-378-1338
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-1550
Mailing Address - Country:US
Mailing Address - Phone:360-378-1338
Mailing Address - Fax:360-378-1830
Practice Address - Street 1:689 AIRPORT CENTER DR SUITE B
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250
Practice Address - Country:US
Practice Address - Phone:360-378-1338
Practice Address - Fax:360-378-8130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA612622200OtherUS NATL PARK SERVICE
WA8937841OtherCRIME VICTIMS
WA602732862OtherUBI
WAJ5122OtherRAILROAD MEDICARE
WAPENDINGOtherMEDICARE
WA50D0990556OtherCLIA
WA612622200OtherUS CUSTOMAS & BORDER PROTECTION
WA7138829Medicaid
WA9451SAOtherREGENCE
WAPOO425655DG2646OtherRAILROAD MEDICARE
WA0152516OtherLABOR AND INDUSTRIES
WA748121OtherGROUP HEALTH COOPERATIVE
WAPENDINGOtherDSHS
WA7135981Medicaid
WA7990344OtherAETNA
WA361929500OtherPARKS NATL L&I
WA0152516OtherLABOR AND INDUSTRIES
WA9451SAOtherREGENCE
WA=========OtherCIGNA BEECH ST
WA50D0990556OtherCLIA
WA=========OtherFIRST CHOICE
WA612622200OtherUS NATL PARK SERVICE
WA7135981Medicaid