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General NPI Number Information
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NPI Number | 1245077577
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Entity Type | Individual
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Provider Name | ANDREW GOODRUM PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/12/2024
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Last Update Date | 06/03/2025
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Provider Practice Location Address
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Address Line | 13690 E 14TH ST STE 200
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City | SAN LEANDRO
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State | CA
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Zip | 94578-2584
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Country | US
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Telephone | 510-297-0550
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 14376
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City | SAN FRANCISCO
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State | CA
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Zip | 94114-0376
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA66152
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License Number State | CA
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