Basic Information
| Provider Information | |||||||||
| NPI: | 1265671796 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODGAME | ||||||||
| FirstName: | BROOKS | ||||||||
| MiddleName: | RANSOM | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1365 CLIFTON RD NE | ||||||||
| Address2: | SUITE B1400 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784898 | ||||||||
| FaxNumber: | 4047784006 | ||||||||
| Practice Location | |||||||||
| Address1: | 1365 CLIFTON RD NE | ||||||||
| Address2: | SUITE B1400 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303221414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047784898 | ||||||||
| FaxNumber: | 4047784006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2009 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 005513 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.