Provider Demographics
NPI:1518363811
Name:GOULD, AUDRA (PA)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:GOULD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18701-3301
Mailing Address - Country:US
Mailing Address - Phone:570-552-6000
Mailing Address - Fax:570-552-6021
Practice Address - Street 1:110 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18701-3301
Practice Address - Country:US
Practice Address - Phone:570-552-6000
Practice Address - Fax:570-552-6021
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant