Provider Demographics
NPI:1609569706
Name:GOSSARD, THOMAS ROBERT
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:ROBERT
Last Name:GOSSARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2637
Mailing Address - Country:US
Mailing Address - Phone:602-812-4312
Mailing Address - Fax:
Practice Address - Street 1:3100 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2637
Practice Address - Country:US
Practice Address - Phone:602-812-4312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program