Provider Demographics
NPI:1447922638
Name:GOUKER, EMILY GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:GOUKER
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 1:270 E DAY RD STE 280
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3452
Mailing Address - Country:US
Mailing Address - Phone:574-271-0268
Mailing Address - Fax:574-271-0395
Practice Address - Street 1:270 E DAY RD STE 280
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3452
Practice Address - Country:US
Practice Address - Phone:574-271-0268
Practice Address - Fax:574-271-0395
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003411A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100092300Medicaid
IN000000090717OtherBCBS
IN110052119OtherRR MIDICARE