Healthcare Provider Details

I. General information

NPI: 1194711911
Provider Name (Legal Business Name): KATHLEEN M GOFF NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 BROAD RD CGH POB SUITE 2V
SYRACUSE NY
13215-2265
US

IV. Provider business mailing address

PO BOX 2003
EAST SYRACUSE NY
13057-4503
US

V. Phone/Fax

Practice location:
  • Phone: 315-492-5005
  • Fax: 315-492-5324
Mailing address:
  • Phone: 315-446-3904
  • Fax: 315-445-2936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF330961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: