Healthcare Provider Details

I. General information

NPI: 1245077577
Provider Name (Legal Business Name): ANDREW GOODRUM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13690 E 14TH ST STE 200
SAN LEANDRO CA
94578-2584
US

IV. Provider business mailing address

PO BOX 14376
SAN FRANCISCO CA
94114-0376
US

V. Phone/Fax

Practice location:
  • Phone: 510-297-0550
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA66152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: