Provider Demographics
NPI:1508837675
Name:GOSVENER, PHILIP ALAN (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:ALAN
Last Name:GOSVENER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 MCCRAY STREET, SUITE 101
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023
Mailing Address - Country:US
Mailing Address - Phone:831-634-4444
Mailing Address - Fax:
Practice Address - Street 1:591 MCCRAY ST STE 101
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2224
Practice Address - Country:US
Practice Address - Phone:831-634-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORS30222Medicare UPIN