Healthcare Provider Details

I. General information

NPI: 1942493630
Provider Name (Legal Business Name): HADDEN F GOODMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HADDEN FORRY

II. Dates (important events)

Enumeration Date: 08/25/2007
Last Update Date: 04/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 ELKRUN HWY 89
ALPINE WY
83128
US

IV. Provider business mailing address

P.O. BOX 3047
ALPINE WY
83128
US

V. Phone/Fax

Practice location:
  • Phone: 307-654-7138
  • Fax: 307-654-7201
Mailing address:
  • Phone: 307-654-7138
  • Fax: 307-654-7201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberWY433
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number433
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: