Provider Demographics
NPI:1639153091
Name:GOODERHAM, CHAD BRIAN (FNP)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:BRIAN
Last Name:GOODERHAM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 SHANNON DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3811
Mailing Address - Country:US
Mailing Address - Phone:907-457-5158
Mailing Address - Fax:
Practice Address - Street 1:1060 GAFFNEY RD
Practice Address - Street 2:
Practice Address - City:FORT WAINWRIGHT
Practice Address - State:AK
Practice Address - Zip Code:99703-5001
Practice Address - Country:US
Practice Address - Phone:907-353-5286
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1927-033363LF0000X
WI363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily