Provider Demographics
NPI:1336499730
Name:GODINA, RAUL (PA-C)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:GODINA
Suffix:
Gender:M
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:PO BOX 191050
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-1050
Mailing Address - Country:US
Mailing Address - Phone:208-955-6522
Mailing Address - Fax:208-955-6503
Practice Address - Street 1:512 N 21ST AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4368
Practice Address - Country:US
Practice Address - Phone:208-809-2875
Practice Address - Fax:208-809-2876
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5210363AM0700X
IDPA-1250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical