Provider Demographics
NPI:1134228554
Name:GOZNER, GERALD (PAC)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:
Last Name:GOZNER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6519
Mailing Address - Country:US
Mailing Address - Phone:920-927-7380
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-927-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42984400Medicaid
WI013020270Medicare ID - Type Unspecified
WI6206770001Medicare NSC
WI42984400Medicaid
WI462364970Medicare PIN
WI019940748Medicare PIN