Provider Demographics
NPI:1689665135
Name:GOODRICH, STEFANIE A (PA)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:A
Last Name:GOODRICH
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 1:100 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01680-1209
Mailing Address - Country:US
Mailing Address - Phone:508-754-3823
Mailing Address - Fax:508-753-0151
Practice Address - Street 1:100 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01680-1209
Practice Address - Country:US
Practice Address - Phone:508-754-3823
Practice Address - Fax:508-753-0151
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1875174400000X
MAPA1875363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP83700Medicare UPIN