Provider Demographics
NPI:1619229564
Name:GOODSITE, MARIJO (PA)
Entity Type:Individual
Prefix:
First Name:MARIJO
Middle Name:
Last Name:GOODSITE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GREENWOOD HTS
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-1049
Mailing Address - Country:US
Mailing Address - Phone:419-217-0061
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical