Provider Demographics
NPI:1710908371
Name:GODDARD, ALAN (PAC)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:GODDARD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 669
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-0669
Mailing Address - Country:US
Mailing Address - Phone:252-209-0237
Mailing Address - Fax:252-209-0197
Practice Address - Street 1:120 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8161
Practice Address - Country:US
Practice Address - Phone:252-332-3548
Practice Address - Fax:252-332-1665
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000104207363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2763347Medicare ID - Type Unspecified
NCQ41548Medicare UPIN