Provider Demographics
NPI:1972546778
Name:GOSE, ROGER L (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:GOSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-2266
Mailing Address - Country:US
Mailing Address - Phone:307-857-3488
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:1005 COLLEGE VIEW DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2266
Practice Address - Country:US
Practice Address - Phone:307-857-3488
Practice Address - Fax:307-857-5215
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY2711A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYA73160Medicare UPIN
WY307921Medicare ID - Type Unspecified