Healthcare Provider Details

I. General information

NPI: 1215982517
Provider Name (Legal Business Name): SUZANNE GOODNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NE MOTHER JOSEPH PL
VANCOUVER WA
98664-3200
US

IV. Provider business mailing address

PO BOX 60000 FILE 74839
SAN FRANCISCO CA
94160-1600
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2142
  • Fax: 360-514-6820
Mailing address:
  • Phone: 360-514-2142
  • Fax: 360-514-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004753
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA100004753
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA155112
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: