Provider Demographics
NPI:1598227977
Name:GOEDKEN, MICHAEL (CNP OR PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GOEDKEN
Suffix:
Gender:M
Credentials:CNP OR PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 GRANDVIEW AVE W
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4701
Mailing Address - Country:US
Mailing Address - Phone:651-353-0571
Mailing Address - Fax:
Practice Address - Street 1:2781 PILOT KNOB RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-1119
Practice Address - Country:US
Practice Address - Phone:651-289-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-03
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6495363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health