Healthcare Provider Details

I. General information

NPI: 1336617059
Provider Name (Legal Business Name): MICAELA L GOEBEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 TANNER PL BLDG H
CLINTON TN
37716-6684
US

IV. Provider business mailing address

PO BOX 787
JACKSBORO TN
37757-0787
US

V. Phone/Fax

Practice location:
  • Phone: 865-264-4012
  • Fax: 423-567-4722
Mailing address:
  • Phone: 423-658-1406
  • Fax: 865-281-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3700
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: