Provider Demographics
NPI:1922263839
Name:GODDARD, TERESA JANAE ELDER SELLENTI (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:JANAE ELDER SELLENTI
Last Name:GODDARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:J
Other - Last Name:SELLENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00849656OtherRAILROAD MEDICARE
MNP00849656OtherRAILROAD MEDICARE