Provider Demographics
NPI:1336821834
Name:GOSSARD, KAITLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:GOSSARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1908 HILCO ST STE B
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-6388
Mailing Address - Country:US
Mailing Address - Phone:704-983-3855
Mailing Address - Fax:
Practice Address - Street 1:1908 HILCO ST STE B
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-6388
Practice Address - Country:US
Practice Address - Phone:704-983-3855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant