Healthcare Provider Details

I. General information

NPI: 1083939680
Provider Name (Legal Business Name): CHARLEEN C GOODCHILD PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3830 ROSEMONT DR
COLUMBUS GA
31904-5659
US

IV. Provider business mailing address

3830 ROSEMONT DR
COLUMBUS GA
31904-5659
US

V. Phone/Fax

Practice location:
  • Phone: 706-221-6770
  • Fax: 706-221-6776
Mailing address:
  • Phone: 706-221-6770
  • Fax: 706-221-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007347
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8208
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number007347
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number007347
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: