Provider Demographics
NPI:1578110482
Name:GOODEN, STEPHANIE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:GOODEN
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 1:5934 TWISTED HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-5254
Mailing Address - Country:US
Mailing Address - Phone:910-991-7003
Mailing Address - Fax:
Practice Address - Street 1:300A E MCKAY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9037
Practice Address - Country:US
Practice Address - Phone:910-862-5500
Practice Address - Fax:910-862-5501
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09347363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical