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NPI Code Detail

MEDICARE: MR. NICHOLAS GRANT GOODMAN P.A.

MEDICARE: MR. NICHOLAS GRANT GOODMAN P.A.
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
1363A00000XPhysician Assistant4697AZ

General Provider Information

NPI Number : 1538450853
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. NICHOLAS GRANT GOODMAN P.A.
Provider Business Mailing Address
First Line : 20717 N 59TH DR
Second Line :
City : GLENDALE
State : AZ
Zip : 85308-6761
Country : US
Telephone Number : 623-337-2689
Fax Number :
Provider Business Practice Location Address
First Line : 4434 N 12TH ST
Second Line :
City : PHOENIX
State : AZ
Zip : 85014-4507
Country : US
Telephone Number : 602-242-8857
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/20/2011
Last Update Date : 03/11/2013

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