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NPI Code Detail

MEDICARE: MS. GRACE DURY GOETHE PA-C

MEDICARE: MS. GRACE DURY GOETHE PA-C
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 Assistant10003471AIN

General Provider Information

NPI Number : 1679142228
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. GRACE DURY GOETHE PA-C
Provider Business Mailing Address
First Line : PO BOX 637764
Second Line :
City : CINCINNATI
State : OH
Zip : 45263-7764
Country : US
Telephone Number : 317-880-3939
Fax Number :
Provider Business Practice Location Address
First Line : 720 ESKENAZI AVE
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46202-5187
Country : US
Telephone Number : 317-880-7666
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2021
Last Update Date : 03/27/2026

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