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NPI Code Detail

MEDICARE: CHAD BRIAN GOODERHAM FNP

MEDICARE: CHAD BRIAN GOODERHAM FNP
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
1363LF0000XFamily Nurse Practitioner1927-033WI
2363LF0000XFamily Nurse PractitionerWI

General Provider Information

NPI Number : 1639153091
Entity Type Code : Individual
Provider Name (Legal Business Name) : CHAD BRIAN GOODERHAM FNP
Provider Business Mailing Address
First Line : 1123 SHANNON DR
Second Line :
City : FAIRBANKS
State : AK
Zip : 99701-3811
Country : US
Telephone Number : 907-457-5158
Fax Number :
Provider Business Practice Location Address
First Line : 1060 GAFFNEY RD
Second Line :
City : FORT WAINWRIGHT
State : AK
Zip : 99703-5001
Country : US
Telephone Number : 907-353-5286
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/30/2005
Last Update Date : 09/11/2025

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