Provider Demographics
NPI:1487089108
Name:GOUGH, SARAH E (NP)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:GOUGH
Suffix:
Gender:F
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:PO BOX 610393
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75261-0393
Mailing Address - Country:US
Mailing Address - Phone:903-291-6187
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:802 MEDICAL CIRCLE
Practice Address - Street 2:SUITE 100
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5100
Practice Address - Country:US
Practice Address - Phone:903-757-6042
Practice Address - Fax:903-232-8213
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX714260363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX325488002Medicaid
TX325488001Medicaid