MEDICARE: SEAN GODDARD NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	1133599	KY
2	363L00000X	Nurse Practitioner	28206231	IN

General Provider Information

NPI Number	:	1285117143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEAN GODDARD NP

Provider Business Mailing Address
First Line	:	9025 COLDWATER RD STE 100
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2071
Country	:	US
Telephone Number	:	260-459-9225
Fax Number	:	260-800-1512

Provider Business Practice Location Address
First Line	:	9025 COLDWATER RD STE 100
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-2071
Country	:	US
Telephone Number	:	260-459-9225
Fax Number	:	260-800-1512

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2018
Last Update Date	:	02/21/2024

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