Provider Demographics
NPI:1356447882
Name:GOODRICH, MARK (PAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 NORTH 2000 WEST
Mailing Address - Street 2:WESTSIDE MEDICAL
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015
Mailing Address - Country:US
Mailing Address - Phone:801-774-8888
Mailing Address - Fax:801-825-8519
Practice Address - Street 1:1477 NORTH 2000 WEST
Practice Address - Street 2:WESTSIDE MEDICAL
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015
Practice Address - Country:US
Practice Address - Phone:801-774-8888
Practice Address - Fax:801-825-8519
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2729721206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005519612Medicare ID - Type Unspecified
P45091Medicare UPIN