Provider Demographics
NPI:1730109547
Name:GOLSON, PERCY E (PA)
Entity Type:Individual
Prefix:MR
First Name:PERCY
Middle Name:E
Last Name:GOLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7025
Mailing Address - Street 2:
Mailing Address - City:AMAGANSETT
Mailing Address - State:NY
Mailing Address - Zip Code:11930
Mailing Address - Country:US
Mailing Address - Phone:631-329-6925
Mailing Address - Fax:631-329-6951
Practice Address - Street 1:815 FIRST AVENUE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401
Practice Address - Country:US
Practice Address - Phone:605-622-5123
Practice Address - Fax:605-622-5906
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD2002975Medicaid
ND25275Medicare PIN
SDS100135Medicare PIN