Provider Demographics
NPI:1598965238
Name:GOULD, ANN M (PA)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:M
Last Name:GOULD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:M
Other - Last Name:HAFFNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0883
Mailing Address - Country:US
Mailing Address - Phone:503-399-1400
Mailing Address - Fax:503-399-1406
Practice Address - Street 1:374 OWENS ST SE
Practice Address - Street 2:STE 100
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4183
Practice Address - Country:US
Practice Address - Phone:503-399-1400
Practice Address - Fax:503-399-1406
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500607877Medicaid
OR145992Medicare PIN