Provider Demographics
NPI:1437250420
Name:GOSTKOWSKI, LISA MARIA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIA
Last Name:GOSTKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 UNION BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-7949
Mailing Address - Country:US
Mailing Address - Phone:631-968-8511
Mailing Address - Fax:
Practice Address - Street 1:1855 UNION BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7949
Practice Address - Country:US
Practice Address - Phone:631-968-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist