Provider Demographics
NPI:1356524862
Name:STASHA GOMINAK, MD, PA
Entity type:Organization
Organization Name:STASHA GOMINAK, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:STASHA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOMINAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-596-3808
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:912
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1951
Mailing Address - Country:US
Mailing Address - Phone:903-596-3808
Mailing Address - Fax:903-596-3815
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:SUITE 912
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-596-3808
Practice Address - Fax:903-596-3815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-07
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0086KVOtherBCBS
TXDB5632OtherRAILROAD MEDICARE
TX164213401Medicaid
TXDB5632OtherRAILROAD MEDICARE
TX00297WMedicare PIN