Provider Demographics
NPI:1699198051
Name:GOLDMAN, MARIA SUZANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:SUZANNE
Last Name:GOLDMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARIA
Other - Middle Name:SUZANNE
Other - Last Name:JERNIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:EMANATE HEALTH QUEEN OF THE VALLEY HOSPITAL MEDICAL STA
Mailing Address - Street 2:1115 SOUTH SUNSET AVENUE
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790
Mailing Address - Country:US
Mailing Address - Phone:863-528-8308
Mailing Address - Fax:
Practice Address - Street 1:EMANATE HEALTH QUEEN OF THE VALLEY HOSPITAL MEDICAL STA
Practice Address - Street 2:1115 SOUTH SUNSET AVENUE
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-374-0067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-21
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9107750363A00000X
CA54388363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant