Provider Demographics
NPI:1629741681
Name:GOSS, ETHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:GOSS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 E BROAD ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9186
Mailing Address - Country:US
Mailing Address - Phone:682-518-8619
Mailing Address - Fax:682-518-8195
Practice Address - Street 1:2975 E BROAD ST STE 200
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9186
Practice Address - Country:US
Practice Address - Phone:682-518-8619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14760208600000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No208600000XAllopathic & Osteopathic PhysiciansSurgery