Healthcare Provider Details

I. General information

NPI: 1265760284
Provider Name (Legal Business Name): JEREMY E GOFTON RNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 05/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 E CAMINO DEL CELADOR
TUCSON AZ
85750-1824
US

IV. Provider business mailing address

5601 E CAMINO DEL CELADOR
TUCSON AZ
85750-1824
US

V. Phone/Fax

Practice location:
  • Phone: 520-979-9178
  • Fax:
Mailing address:
  • Phone: 520-979-9178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number125349
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN139696
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: