Provider Demographics
NPI:1679911812
Name:GODIN, ANDREW S (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:S
Last Name:GODIN
Suffix:
Gender:M
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 1:2502 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5252
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-496-4705
Practice Address - Street 1:2502 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5252
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4705
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3138-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant