Provider Demographics
NPI:1588671622
Name:GOCHNOUR, BRETT SHANE (DO)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:SHANE
Last Name:GOCHNOUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 W MOHAVE RD
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:AZ
Mailing Address - Zip Code:85344-6349
Mailing Address - Country:US
Mailing Address - Phone:928-669-7311
Mailing Address - Fax:928-669-7415
Practice Address - Street 1:150 E TYSON ROAD
Practice Address - Street 2:
Practice Address - City:QUARTZSITE
Practice Address - State:AZ
Practice Address - Zip Code:85346
Practice Address - Country:US
Practice Address - Phone:928-927-8747
Practice Address - Fax:928-927-8748
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4481OtherAZ STATE LICENSE
AZZ196548OtherMEDICARE NUMBER
AZ230943Medicaid
AZ230943Medicaid
ID1133950Medicare Oscar/Certification