Provider Demographics
NPI:1891709796
Name:GOSS, JACQUELINE RAE (PA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:RAE
Last Name:GOSS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RANGE RD
Mailing Address - Street 2:
Mailing Address - City:UNDERHILL
Mailing Address - State:VT
Mailing Address - Zip Code:05489-9410
Mailing Address - Country:US
Mailing Address - Phone:802-899-3638
Mailing Address - Fax:802-847-5963
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:EMERGENCY DEPT-MAIN PAVILION
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-3982
Practice Address - Fax:802-847-5963
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030231207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0AP0891Medicaid
VT0AP0891Medicaid
S67729Medicare UPIN