Provider Demographics
NPI:1639229826
Name:GOETZ, COLLEEN M (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:GOETZ
Suffix:
Gender:F
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 1:400 HINCKLEY BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-6152
Mailing Address - Country:US
Mailing Address - Phone:517-205-8991
Mailing Address - Fax:517-205-0114
Practice Address - Street 1:400 HINCKLEY BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-6152
Practice Address - Country:US
Practice Address - Phone:517-205-8991
Practice Address - Fax:517-205-0114
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002550363A00000X
MI5601006249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant