MEDICARE: MISS MICAELA L GOEBEL PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	3700	TN

General Provider Information

NPI Number	:	1336617059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MICAELA L GOEBEL PA-C

Provider Business Mailing Address
First Line	:	PO BOX 787
Second Line	:
City	:	JACKSBORO
State	:	TN
Zip	:	37757-0787
Country	:	US
Telephone Number	:	423-658-1406
Fax Number	:	865-281-1625

Provider Business Practice Location Address
First Line	:	120 TANNER PL BLDG H
Second Line	:
City	:	CLINTON
State	:	TN
Zip	:	37716-6684
Country	:	US
Telephone Number	:	865-264-4012
Fax Number	:	423-567-4722

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/12/2018
Last Update Date	:	10/21/2019

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