Provider Demographics
NPI:1386807030
Name:GOSSAGE, IVAN ROBERT (NP)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:ROBERT
Last Name:GOSSAGE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 HUMBOLDT RD STE 3
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95928-9199
Mailing Address - Country:US
Mailing Address - Phone:530-899-3370
Mailing Address - Fax:
Practice Address - Street 1:1660 HUMBOLDT RD STE 3
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95928-9199
Practice Address - Country:US
Practice Address - Phone:530-530-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA808252163WP0808X
CA231037164X00000X
CA95014269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse