Provider Demographics
NPI:1356483119
Name:GOODRICH, ROSS (PA)
Entity Type:Individual
Prefix:MR
First Name:ROSS
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0848
Mailing Address - Country:US
Mailing Address - Phone:530-226-1721
Mailing Address - Fax:530-224-2742
Practice Address - Street 1:1441 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-0848
Practice Address - Country:US
Practice Address - Phone:530-226-1721
Practice Address - Fax:530-224-2742
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP27412Medicare UPIN
CA0PA130040Medicare ID - Type Unspecified