Provider Demographics
NPI:1598730715
Name:GOMOLL, ADAM T (PA C)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:T
Last Name:GOMOLL
Suffix:
Gender:M
Credentials:PA C
Other - Prefix:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2601 COOLIDGE RD STE 200
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-6381
Practice Address - Country:US
Practice Address - Phone:517-203-3000
Practice Address - Fax:517-203-3003
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601005313363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP31170016Medicare PIN
MIP31190017Medicare PIN
MI0N13520006Medicare PIN