Healthcare Provider Details

I. General information

NPI: 1831492610
Provider Name (Legal Business Name): BECKY GOODSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 S STAPLEY DR STE 111
MESA AZ
85204-5060
US

IV. Provider business mailing address

2531 S GILBERT RD STE 111
GILBERT AZ
85295-5892
US

V. Phone/Fax

Practice location:
  • Phone: 480-398-1220
  • Fax: 480-398-1230
Mailing address:
  • Phone: 480-398-1220
  • Fax: 480-983-4317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN137766
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP3868
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: