Provider Demographics
NPI:1003589383
Name:GOODMAN, CLARA MICHELLE
Entity Type:Individual
Prefix:
First Name:CLARA
Middle Name:MICHELLE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 E MCKELLIPS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-9654
Mailing Address - Country:US
Mailing Address - Phone:602-491-0703
Mailing Address - Fax:480-631-0581
Practice Address - Street 1:3530 S VAL VISTA DR STE C101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7318
Practice Address - Country:US
Practice Address - Phone:602-491-0703
Practice Address - Fax:833-661-1781
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8716363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ125904Medicaid