Provider Demographics
NPI:1053498956
Name:GODBOLD, STEPHANIE A (PA C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:GODBOLD
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 EVES DR # A
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3195
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:
Practice Address - Street 1:200 BOWMAN DR
Practice Address - Street 2:SUITE E-100
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9623
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00167100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJQ76492Medicare UPIN