Provider Demographics
NPI:1184190878
Name:GORAL, DEBRA
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:GORAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1317 PARTRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-8840
Mailing Address - Country:US
Mailing Address - Phone:623-226-9429
Mailing Address - Fax:
Practice Address - Street 1:7223 LEE DEFOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-3236
Practice Address - Country:US
Practice Address - Phone:443-430-8312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-19
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN175069163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$Medicaid