Healthcare Provider Details

I. General information

NPI: 1356098271
Provider Name (Legal Business Name): BOBBY EUGENE GOODSON SRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

162 MARCUS WAY APT 3
ABINGDON VA
24210-4177
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-6111
  • Fax:
Mailing address:
  • Phone: 276-696-2657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number0001265704
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: