Provider Demographics
NPI:1518948207
Name:GOLDSTEIN, AUDREY H (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:H
Last Name:GOLDSTEIN
Suffix:
Gender:F
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 1:8340 E MARLENA CIR N
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-4457
Mailing Address - Country:US
Mailing Address - Phone:520-991-0561
Mailing Address - Fax:
Practice Address - Street 1:8340 E MARLENA CIR N
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-4457
Practice Address - Country:US
Practice Address - Phone:520-991-0561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1587363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ157984Medicaid
AZZWCBBMOtherGROUP MEDICARE ID
AZ005472OtherGROUP MEDICAID ID
AZCS7943OtherGROUP MEDICARE RAILROAD ID & PTAN
AZP00735788OtherMEDICARE RAILROAD
AZ1518948207OtherPHYSCIAN ASSISTANT INDIVIDUAL NPI
AZ1841261989OtherGROUP NPI
AZP00735788OtherMEDICARE RAILROAD
AZZ123529Medicare PIN