Healthcare Provider Details

I. General information

NPI: 1386052777
Provider Name (Legal Business Name): ERIC JAMES GODDEYNE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2014
Last Update Date: 01/13/2026
Certification Date: 01/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 SHAWANO AVE
GREEN BAY WI
54303-3216
US

IV. Provider business mailing address

PO BOX 19070
GREEN BAY WI
54307-9070
US

V. Phone/Fax

Practice location:
  • Phone: 920-496-4700
  • Fax:
Mailing address:
  • Phone: 920-496-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3402-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3204-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: