Provider Demographics
NPI:1346720653
Name:GOODRICH, RILEY RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:RICHARD
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD, EAST
Practice Address - Street 2:STE 203
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:207-523-8590
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPAN1826363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty