Provider Demographics
NPI:1871716282
Name:GOTTHARDT, JANE F (N P)
Entity type:Individual
Prefix:MRS
First Name:JANE
Middle Name:F
Last Name:GOTTHARDT
Suffix:
Gender:F
Credentials:N P
Other - Prefix:MISS
Other - First Name:JANE
Other - Middle Name:F
Other - Last Name:OVERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1122 KERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:NY
Mailing Address - Zip Code:13783-3900
Mailing Address - Country:US
Mailing Address - Phone:607-422-7656
Mailing Address - Fax:
Practice Address - Street 1:2 TITUS PL
Practice Address - Street 2:
Practice Address - City:WALTON
Practice Address - State:NY
Practice Address - Zip Code:13856-1455
Practice Address - Country:US
Practice Address - Phone:607-865-2100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY365737-01163W00000X
NYF331819-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY365737-1OtherFAMILY NURSE PRACTITIONER
NY96N191Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER