Basic Information
| Provider Information | |||||||||
| NPI: | 1871763797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODE | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8500 | ||||||||
| Address2: | LOCKBOX 7642 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191787642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818115 | ||||||||
| FaxNumber: | 8132818656 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775502725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818115 | ||||||||
| FaxNumber: | 8132818656 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05733 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8Y3947 | 01 | TX | BCBS | OTHER |