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General NPI Number Information
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NPI Number | 1699843342
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Entity Type | Individual
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Provider Name | JESSE LEE GOODMAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/01/2006
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Last Update Date | 04/16/2013
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Provider Practice Location Address
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Address Line | 1515 NE LAWRIE TATUM RD
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City | LAWTON
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State | OK
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Zip | 73507-3002
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Country | US
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Telephone | 580-354-5100
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Fax | 580-354-5105
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Provider Business Mailing Address
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Address Line | 1515 NE LAWRIE TATUM RD
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City | LAWTON
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State | OK
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Zip | 73507-3002
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Country | US
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Telephone | 580-354-5100
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Fax | 580-354-5105
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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 | 2244
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License Number State | OK
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