Provider Demographics
NPI:1841928322
Name:GOSSELIN, NICOLE GALLAGHER (PA-S2)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:GALLAGHER
Last Name:GOSSELIN
Suffix:
Gender:F
Credentials:PA-S2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2656
Mailing Address - Country:US
Mailing Address - Phone:860-573-3539
Mailing Address - Fax:
Practice Address - Street 1:13 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1804
Practice Address - Country:US
Practice Address - Phone:860-573-3539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant