1700813516 NPI number — MS. COURTNEY HANNA GOODMAN PA-C, MPA-S, B.S.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700813516 NPI number — MS. COURTNEY HANNA GOODMAN PA-C, MPA-S, B.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOODMAN
Provider First Name:
COURTNEY
Provider Middle Name:
HANNA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C, MPA-S, B.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700813516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1408 BENDING BROOK CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904-5394
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-366-1850
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 MEDICAL CENTER BLVD STE I
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904-3163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-699-3161
Provider Business Practice Location Address Fax Number:
936-699-3162
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA01131 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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