Provider Demographics
NPI:1902919392
Name:GOESSLER, LARAINE LACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:LARAINE
Middle Name:LACEY
Last Name:GOESSLER
Suffix:
Gender:F
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 1:1420 VICEROY DR
Mailing Address - Street 2:ATTN: LASHUNDA JOHNSON
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235-2208
Mailing Address - Country:US
Mailing Address - Phone:214-358-2300
Mailing Address - Fax:214-366-6127
Practice Address - Street 1:3604 LIVE OAK ST STE 100
Practice Address - Street 2:ATTN: LASHUNDA JOHNSON
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6169
Practice Address - Country:US
Practice Address - Phone:214-358-2300
Practice Address - Fax:214-366-6330
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00685363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB128513Medicare PIN
TX83N511Medicare ID - Type UnspecifiedMCR #