Provider Demographics
NPI:1366715625
Name:GOBLE, JACK A JR (PA-C)
Entity type:Individual
Prefix:PROF
First Name:JACK
Middle Name:A
Last Name:GOBLE
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LEE ST
Mailing Address - Street 2:
Mailing Address - City:STEWARTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17363-4061
Mailing Address - Country:US
Mailing Address - Phone:717-578-6660
Mailing Address - Fax:
Practice Address - Street 1:10755 FALLS RD
Practice Address - Street 2:SUITE 160
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4515
Practice Address - Country:US
Practice Address - Phone:410-285-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-17
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001029363AM0700X
PAMA002128L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD149619Medicare PIN
MD945LMedicare PIN