Provider Demographics
NPI:1912668013
Name:POUDEL, GOMA
Entity Type:Individual
Prefix:
First Name:GOMA
Middle Name:
Last Name:POUDEL
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 1:7326 BROOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-5275
Mailing Address - Country:US
Mailing Address - Phone:319-536-5670
Mailing Address - Fax:
Practice Address - Street 1:7326 BROOKE BLVD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-5275
Practice Address - Country:US
Practice Address - Phone:319-536-5670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-02
Last Update Date:2022-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00000000Medicaid