Provider Demographics
NPI:1760810832
Name:GOODMAN, KRISTY MARIE (MS, MPH, PA-C)
Entity Type:Individual
Prefix:MISS
First Name:KRISTY
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MS, MPH, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Mailing Address - Street 1:4854 WHISKEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:NY
Mailing Address - Zip Code:14590-9318
Mailing Address - Country:US
Mailing Address - Phone:315-594-6043
Mailing Address - Fax:
Practice Address - Street 1:400 W 30TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3320
Practice Address - Country:US
Practice Address - Phone:213-284-3200
Practice Address - Fax:213-284-3350
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA51236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant