1245417492 NPI number — MR. PAUL A GOBOURNE CRNP

Table of content: MR. PAUL A GOBOURNE CRNP (NPI 1245417492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245417492 NPI number — MR. PAUL A GOBOURNE CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOBOURNE
Provider First Name:
PAUL
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245417492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1748 PORTAL DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20012-1116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-722-7786
Provider Business Mailing Address Fax Number:
202-722-1123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8901 WISCONSIN AVE
Provider Second Line Business Practice Location Address:
BLDG. 8 RM 3169C
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20889-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-400-1012
Provider Business Practice Location Address Fax Number:
301-295-8963
Provider Enumeration Date:
01/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN965066 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: R132556 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 035904300 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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