Healthcare Provider Details

I. General information

NPI: 1518539907
Provider Name (Legal Business Name): MICHAEL CHARLES GODDEYNE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W OKLAHOMA AVE
MILWAUKEE WI
53215-4330
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-489-4190
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5489
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5489-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: