Provider Demographics
NPI:1750327797
Name:GOODSPEED, REBECCA J (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:GOODSPEED
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-302-6450
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 W CHERRY LN
Practice Address - Street 2:SUITE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8531
Practice Address - Country:US
Practice Address - Phone:208-302-6450
Practice Address - Fax:208-302-6455
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA524363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807176000Medicaid
Q45851Medicare UPIN
ID807176000Medicaid