Provider Demographics
NPI:1639130057
Name:GOEDERS, MARC JAMES (PA)
Entity Type:Individual
Prefix:MR
First Name:MARC
Middle Name:JAMES
Last Name:GOEDERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12129 UNIVERSITY AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8287
Mailing Address - Country:US
Mailing Address - Phone:515-400-3550
Mailing Address - Fax:
Practice Address - Street 1:12129 UNIVERSITY AVE STE 100
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8287
Practice Address - Country:US
Practice Address - Phone:515-400-3550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001294363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P78887Medicare UPIN
I10724Medicare ID - Type Unspecified