Healthcare Provider Details

I. General information

NPI: 1326033978
Provider Name (Legal Business Name): PATRICIA LYNN GOODEMOTE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA LYNN GANNON MD

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E 10TH ST
ATLANTIC IA
50022-1936
US

IV. Provider business mailing address

1501 E 10TH ST
ATLANTIC IA
50022-1936
US

V. Phone/Fax

Practice location:
  • Phone: 712-243-7430
  • Fax:
Mailing address:
  • Phone: 850-883-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-109181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: