Provider Demographics
NPI:1902311319
Name:GOTTHARDT, LEE JAMES
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:JAMES
Last Name:GOTTHARDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4477
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:
Practice Address - Street 1:12655 WARWICK BLVD STE B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2501
Practice Address - Country:US
Practice Address - Phone:757-595-3570
Practice Address - Fax:757-592-9280
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175673363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner