Basic Information
| Provider Information | |||||||||
| NPI: | 1528084308 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | REBECCA | ||||||||
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| Credential: | RNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 COULTER RD | ||||||||
| Address2: | ATTN MEDICAL STAFF OFFICE | ||||||||
| City: | CLIFTON SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144321122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154621464 | ||||||||
| FaxNumber: | 3154622487 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 COULTER RD | ||||||||
| Address2: | |||||||||
| City: | CLIFTON SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144321122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221900 | ||||||||
| FaxNumber: | 5859221002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 330760 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 175009BS | 01 | PREFERRED CARE | OTHER | P019330760 | 01 | BLUE CHOICE | OTHER |