Provider Demographics
NPI:1063485985
Name:GOODE, SUSAN K (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:GOODE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 ELM AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24013
Mailing Address - Country:US
Mailing Address - Phone:540-224-5170
Mailing Address - Fax:
Practice Address - Street 1:46 WESLEY RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3082
Practice Address - Country:US
Practice Address - Phone:540-992-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024-000048363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7788037Medicaid
000307C04Medicare PIN
VA7788037Medicaid