Provider Demographics
NPI:1982690681
Name:GOOGE, KENNETH D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:GOOGE
Suffix:
Gender:M
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 1:491 MARINER BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-5680
Mailing Address - Country:US
Mailing Address - Phone:353-515-6000
Mailing Address - Fax:
Practice Address - Street 1:605 LAMAR AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3211
Practice Address - Country:US
Practice Address - Phone:352-796-9990
Practice Address - Fax:352-796-2226
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290140400Medicaid
P00107882OtherRAILROAD MEDICARE
FLY01ELOtherBCBS OF FLORIDA
FLY01ELOtherBCBS OF FLORIDA
FLY01ELOtherBCBS OF FLORIDA
FL290140400Medicaid