Provider Demographics
NPI:1619232857
Name:GOSS, ELLEN CRYSTAL (FNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:CRYSTAL
Last Name:GOSS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 E CAMP LOWELL DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1275
Mailing Address - Country:US
Mailing Address - Phone:520-319-5922
Mailing Address - Fax:520-319-6128
Practice Address - Street 1:4790 E CAMP LOWELL DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-1275
Practice Address - Country:US
Practice Address - Phone:520-319-5922
Practice Address - Fax:520-319-6128
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ714721Medicaid
AZZ154917Medicare UPIN
AZ714721Medicaid