MEDICARE: BRENT E GOODEN 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	661891	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8N9841	OTHER	TX	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457389660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT E GOODEN NP

Provider Business Mailing Address
First Line	:	2035 FORT WORTH HWY
Second Line	:	SUITE 100
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4782
Country	:	US
Telephone Number	:	817-594-0496
Fax Number	:	817-599-6533

Provider Business Practice Location Address
First Line	:	2035 FORT WORTH HWY
Second Line	:	SUITE 100
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-4782
Country	:	US
Telephone Number	:	817-594-0496
Fax Number	:	817-599-6533

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

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	03/09/2012

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