Provider Demographics
NPI:1053450387
Name:GOLDBERG, JOANN (AA)
Entity Type:Individual
Prefix:
First Name:JOANN
Middle Name:
Last Name:GOLDBERG
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:JOANN
Other - Middle Name:
Other - Last Name:BRENNAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:804 SCOTT NIXON MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2464
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:
Practice Address - Street 1:400 MALL BLVD
Practice Address - Street 2:STE T
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4861
Practice Address - Country:US
Practice Address - Phone:912-355-7214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001492363AM0700X
367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA43ZCBN12Medicare UPIN