Provider Demographics
NPI:1477737526
Name:GOLDBACH, VANESSA L (PA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:L
Last Name:GOLDBACH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VANESSA
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2441 OAK MYRTLE LN STE 101
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6334
Mailing Address - Country:US
Mailing Address - Phone:813-406-4835
Mailing Address - Fax:813-994-4835
Practice Address - Street 1:2441 OAK MYRTLE LN STE 101
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6334
Practice Address - Country:US
Practice Address - Phone:813-406-4835
Practice Address - Fax:813-994-4835
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9103811207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL292973200Medicaid
FLY0K5QOtherBLUE CROSS
FL292973200Medicaid
FLAL121Medicare PIN
FLAI121ZMedicare PIN