Provider Demographics
NPI:1639126162
Name:GOMULKA, KERRY (PA)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:GOMULKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:
Other - Last Name:NOETZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:SUITE 101
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-294-2733
Practice Address - Fax:845-294-6486
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010206-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ78333Medicare UPIN
8352L1L663Medicare PIN