Provider Demographics
NPI:1265865414
Name:GOODMAN, AMY KAY (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KAY
Last Name:GOODMAN
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 1:111 MARBLE MILL RD NW
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1047
Mailing Address - Country:US
Mailing Address - Phone:770-422-1013
Mailing Address - Fax:770-514-5996
Practice Address - Street 1:111 MARBLE MILL RD NW
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1047
Practice Address - Country:US
Practice Address - Phone:770-422-1013
Practice Address - Fax:770-514-5996
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant