Provider Demographics
NPI:1801032461
Name:GOTTSCHALK, JOHN THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:THOMAS
Last Name:GOTTSCHALK
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 1:312 BRIGG DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-7998
Mailing Address - Country:US
Mailing Address - Phone:214-680-8161
Mailing Address - Fax:
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223
Practice Address - Country:US
Practice Address - Phone:270-412-0742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-31
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2234363A00000X
TNPA2902363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant