Provider Demographics
NPI:1699843342
Name:GOODMAN, JESSE LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JESSE
Middle Name:LEE
Last Name:GOODMAN
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3002
Mailing Address - Country:US
Mailing Address - Phone:580-354-5100
Mailing Address - Fax:580-354-5105
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5100
Practice Address - Fax:580-354-5105
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2013-04-16
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Provider Licenses
StateLicense IDTaxonomies
OK2244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant