Provider Demographics
NPI:1205051216
Name:GOLBOURNE, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:GOLBOURNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:TREVOR
Other - Middle Name:
Other - Last Name:GOLBOURNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:618 POWELLS LN
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1321
Mailing Address - Country:US
Mailing Address - Phone:516-445-6128
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:10G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1147
Practice Address - Country:US
Practice Address - Phone:212-636-3400
Practice Address - Fax:212-636-3296
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005726363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical