Provider Demographics
NPI:1205188786
Name:GOODY, BRIAN EARL (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EARL
Last Name:GOODY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10612 PARK AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-5864
Mailing Address - Country:US
Mailing Address - Phone:360-584-6775
Mailing Address - Fax:
Practice Address - Street 1:915 ANDERSON DR
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1006
Practice Address - Country:US
Practice Address - Phone:360-537-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.60316095363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical