Provider Demographics
NPI:1245408814
Name:GOODYEAR, MARJORIE MILLARD (PA)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:MILLARD
Last Name:GOODYEAR
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 1:408 S HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-2533
Mailing Address - Country:US
Mailing Address - Phone:303-995-1736
Mailing Address - Fax:
Practice Address - Street 1:3600 E ALAMEDA AVE STE 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3135
Practice Address - Country:US
Practice Address - Phone:720-266-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2084363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical