Provider Demographics
NPI:1124477377
Name:GOUGH, CHELSEA
Entity type:Individual
Prefix:
First Name:CHELSEA
Middle Name:
Last Name:GOUGH
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:PO BOX 602478
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2478
Mailing Address - Country:US
Mailing Address - Phone:704-403-6240
Mailing Address - Fax:
Practice Address - Street 1:340 JAKE ALEXANDER BLVD. WEST
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-403-6240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06438363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1124477377Medicaid
SC2745PAMedicaid
NC1124477377Medicaid
SC2745PAMedicaid
NCNCU919CMedicare PIN
NCNCU919DMedicare PIN
NCNCU919AMedicare PIN