Provider Demographics
NPI:1053309740
Name:GOODMAN, SANDRA KAY (CNM)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:KAY
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 FLORMANN ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-4679
Mailing Address - Country:US
Mailing Address - Phone:605-342-7400
Mailing Address - Fax:
Practice Address - Street 1:640 FLORMANN ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-4679
Practice Address - Country:US
Practice Address - Phone:605-342-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN074389 APO3126367A00000X
MSR859135367A00000X
SD000041176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0120312Medicaid
MSS42128Medicare UPIN