Basic Information
| Provider Information | |||||||||
| NPI: | 1518389121 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOMBOSI | ||||||||
| FirstName: | JULIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 GRAMPIAN BLVD | ||||||||
| Address2: | 4 SOUTH | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703207690 | ||||||||
| FaxNumber: | 5703207692 | ||||||||
| Practice Location | |||||||||
| Address1: | 1100 GRAMPIAN BLVD | ||||||||
| Address2: | 4 SOUTH | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177011909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703207690 | ||||||||
| FaxNumber: | 5703207692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2014 | ||||||||
| LastUpdateDate: | 01/16/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | RN262305L | PA | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1015976760001 | 05 | PA | MEDICAID |