Healthcare Provider Details

I. General information

NPI: 1780648451
Provider Name (Legal Business Name): SHIRLEY GRAY GOODMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BRENNER AVE
SALISBURY NC
28144-2515
US

IV. Provider business mailing address

801 S FULTON ST
SALISBURY NC
28144-5343
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-9000
  • Fax: 704-638-3857
Mailing address:
  • Phone: 704-642-1413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100335
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: