Provider Demographics
NPI:1306396759
Name:GOEDECKE, CHARLES MICHAEL (LSA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:GOEDECKE
Suffix:
Gender:M
Credentials:LSA
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1103 HAYLOFT LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-1456
Mailing Address - Country:US
Mailing Address - Phone:210-445-9456
Mailing Address - Fax:
Practice Address - Street 1:16100 SH 288
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584
Practice Address - Country:US
Practice Address - Phone:210-445-9456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-10
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical