Provider Demographics
NPI:1922546324
Name:GODWIN-TART, LEA ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:LEA ANNA
Middle Name:
Last Name:GODWIN-TART
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 1:1 EMBARCADERO CTR STE 1900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94111-3723
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:905 W MAIN ST STE 18A
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27701-2054
Practice Address - Country:US
Practice Address - Phone:888-663-6331
Practice Address - Fax:919-646-9865
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9110077363A00000X
CAPA56983363A00000X
NC0010-12495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant