Basic Information
Provider Information | |||||||||
NPI: | 1215046768 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOODMAN | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | G | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5325 FARAON ST | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645063488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162717986 | ||||||||
FaxNumber: | 8162717986 | ||||||||
Practice Location | |||||||||
Address1: | 5325 FARAON ST | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645063488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162717986 | ||||||||
FaxNumber: | 8162717986 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 10/13/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 095469 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 200553990C | 05 | KS |   | MEDICAID | 200553990B | 05 | KS |   | MEDICAID | 425076601 | 05 | MO |   | MEDICAID | 540492501 | 05 | MO |   | MEDICAID | 200553990A | 05 | KS |   | MEDICAID | 10001503301 | 01 | MO | COMMUNITY HEALTH PLAN | OTHER | 30405021 | 01 |   | BCBS | OTHER | 200553990D | 05 | KS |   | MEDICAID |