Healthcare Provider Details

I. General information

NPI: 1770091027
Provider Name (Legal Business Name): JOSHUA AARON GOLDBERG BC-AGCNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2018
Last Update Date: 01/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

671 OLD HIGHWAY 48
CLARKSVILLE TN
37040-8691
US

V. Phone/Fax

Practice location:
  • Phone: 270-412-8376
  • Fax:
Mailing address:
  • Phone: 610-850-3946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAP133925
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAP133925
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: