Provider Demographics
NPI:1164857520
Name:GOLDNER, ALEXANDER MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:MICHAEL
Last Name:GOLDNER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:ALEX
Other - Middle Name:M
Other - Last Name:GOLDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 SW 26TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97331-8624
Practice Address - Country:US
Practice Address - Phone:541-737-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2013-0058363AM0700X
ORPA191536363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM326185YKWYOtherMEDICARE PTAN
NM72728825Medicaid