Provider Demographics
NPI:1083824783
Name:GOODROE, COLLEEN PATRICIA (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:PATRICIA
Last Name:GOODROE
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 1:7610 STEMMONS FWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4231
Mailing Address - Country:US
Mailing Address - Phone:214-689-5960
Mailing Address - Fax:214-689-3804
Practice Address - Street 1:3142 HORIZON RD
Practice Address - Street 2:SUITE 209
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7809
Practice Address - Country:US
Practice Address - Phone:972-771-2222
Practice Address - Fax:972-771-3350
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1148363A00000X
TXPA06266363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L21379Medicare PIN