Basic Information
Provider Information | |||||||||
NPI: | 1881751360 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOETZ | ||||||||
FirstName: | EUNICE | ||||||||
MiddleName: | JEON | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JEON | ||||||||
OtherFirstName: | EUNICE | ||||||||
OtherMiddleName: | NAMI | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6300 HOSPITAL PKWY STE 145 | ||||||||
Address2: |   | ||||||||
City: | JOHNS CREEK | ||||||||
State: | GA | ||||||||
PostalCode: | 300971828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047784898 | ||||||||
FaxNumber: | 4047784006 | ||||||||
Practice Location | |||||||||
Address1: | 1365 CLIFTON ROAD | ||||||||
Address2: | SUITE B1400 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30322 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4047784898 | ||||||||
FaxNumber: | 4047784006 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/03/2007 | ||||||||
LastUpdateDate: | 05/28/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA051233 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 7430 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.