Healthcare Provider Details

I. General information

NPI: 1457998320
Provider Name (Legal Business Name): DESIREE GOENAGA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 MAIN AVE STE 101
CLIFTON NJ
07011-2333
US

IV. Provider business mailing address

251 E BRINGHURST ST
PHILADELPHIA PA
19144-1799
US

V. Phone/Fax

Practice location:
  • Phone: 973-928-3088
  • Fax:
Mailing address:
  • Phone: 215-844-1020
  • Fax: 215-844-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061236
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00548400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: