Healthcare Provider Details

I. General information

NPI: 1255637740
Provider Name (Legal Business Name): ANDREW GOODNER P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 PEACHTREE RD NW
ATLANTA GA
30309-1281
US

IV. Provider business mailing address

355 TOWER RD NE SUITE 300
MARIETTA GA
30060-9408
US

V. Phone/Fax

Practice location:
  • Phone: 404-367-3014
  • Fax:
Mailing address:
  • Phone: 770-426-4721
  • Fax: 770-424-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: