Provider Demographics
NPI:1942428255
Name:GOULBOURNE-SCOTT, ALISA STEPHANIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:STEPHANIE
Last Name:GOULBOURNE-SCOTT
Suffix:
Gender:F
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 1:19 HENRIETTA CT
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-2938
Mailing Address - Country:US
Mailing Address - Phone:201-670-7498
Mailing Address - Fax:
Practice Address - Street 1:19 HENRIETTA CT
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2938
Practice Address - Country:US
Practice Address - Phone:201-670-7498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0041901363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant