Provider Demographics
NPI:1205287943
Name:GOBOURNE, LANIK L (PA)
Entity type:Individual
Prefix:
First Name:LANIK
Middle Name:L
Last Name:GOBOURNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LANIK
Other - Middle Name:
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2216
Mailing Address - Country:US
Mailing Address - Phone:631-487-5801
Mailing Address - Fax:
Practice Address - Street 1:27005 76TH AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1402
Practice Address - Country:US
Practice Address - Phone:718-470-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00399700363A00000X
NY019879-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant