Provider Demographics
NPI:1073796108
Name:GOODBREAD, MICHELE L (PA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:GOODBREAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-727-6319
Mailing Address - Fax:423-727-4164
Practice Address - Street 1:222 OAK ST
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-1526
Practice Address - Country:US
Practice Address - Phone:423-727-6319
Practice Address - Fax:423-727-4164
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA006782363AM0700X
PAMA053005363AM0700X
TN1774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516442Medicaid
3703867Medicare PIN
3703865Medicare PIN
TN1516442Medicaid