Healthcare Provider Details

I. General information

NPI: 1013305895
Provider Name (Legal Business Name): AMBER GOODMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2015
Last Update Date: 10/07/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 LAKELAND DR STE 61
JACKSON MS
39216-4634
US

IV. Provider business mailing address

970 LAKELAND DR STE 61
JACKSON MS
39216-4634
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-7850
  • Fax: 601-366-8507
Mailing address:
  • Phone: 601-982-7850
  • Fax: 601-366-8507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00345
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: