Provider Demographics
NPI:1518389121
Name:GOMBOSI, JULIAN
Entity Type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:GOMBOSI
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 1:1100 GRAMPIAN BLVD
Mailing Address - Street 2:4 SOUTH
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1909
Mailing Address - Country:US
Mailing Address - Phone:570-320-7690
Mailing Address - Fax:570-320-7692
Practice Address - Street 1:1100 GRAMPIAN BLVD
Practice Address - Street 2:4 SOUTH
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-1909
Practice Address - Country:US
Practice Address - Phone:570-320-7690
Practice Address - Fax:570-320-7692
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN262305L164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015976760001Medicaid