Provider Demographics
NPI:1578652855
Name:GODBOUT, JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:M
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 1:4 ROSSI CIR
Mailing Address - Street 2:SUITE 141
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93907-2362
Mailing Address - Country:US
Mailing Address - Phone:831-757-4444
Mailing Address - Fax:831-757-4419
Practice Address - Street 1:285 MERCEY SPRINGS RD
Practice Address - Street 2:STE A
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3878
Practice Address - Country:US
Practice Address - Phone:209-829-0444
Practice Address - Fax:209-829-0445
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL161ZMedicare PIN