Provider Demographics
NPI:1891984613
Name:GOLDMANN, MARY E (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:GOLDMANN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 COOKS HILL RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-9073
Mailing Address - Country:US
Mailing Address - Phone:360-736-2889
Mailing Address - Fax:
Practice Address - Street 1:1900 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-736-2889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant