Provider Demographics
NPI:1134407356
Name:GOOSE CREEK FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:GOOSE CREEK FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KAWULOK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:307-674-1744
Mailing Address - Street 1:304 COFFEEN AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4803
Mailing Address - Country:US
Mailing Address - Phone:307-674-1744
Mailing Address - Fax:307-674-1752
Practice Address - Street 1:304 COFFEEN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4803
Practice Address - Country:US
Practice Address - Phone:307-674-1744
Practice Address - Fax:307-674-1752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11988.1019261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013242502OtherNPI #
WYW23011Medicare PIN