Healthcare Provider Details

I. General information

NPI: 1790704815
Provider Name (Legal Business Name): MARC WILLIAM GOODBOY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 3RD ST SE SUITE 210
PUYALLUP WA
98372-3742
US

IV. Provider business mailing address

805 MADISON ST SUITE 901
SEATTLE WA
98104-1172
US

V. Phone/Fax

Practice location:
  • Phone: 253-840-4994
  • Fax: 253-770-1105
Mailing address:
  • Phone: 206-264-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60064004
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC0119
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60064004
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA60064004
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: