Healthcare Provider Details

I. General information

NPI: 1376791673
Provider Name (Legal Business Name): TINA GOODPASTURE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 N ELM ST SUITE 300
GREENSBORO NC
27401-6309
US

IV. Provider business mailing address

1103 N ELM ST SUITE 300
GREENSBORO NC
27401-6309
US

V. Phone/Fax

Practice location:
  • Phone: 336-271-3331
  • Fax: 336-271-3724
Mailing address:
  • Phone: 336-271-3331
  • Fax: 336-271-3724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5004054
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: