Provider Demographics
NPI:1992863872
Name:GOODSON, ROCELIOUS III (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ROCELIOUS
Middle Name:
Last Name:GOODSON
Suffix:III
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 1:5790 NEWBERRY ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-8300
Mailing Address - Country:US
Mailing Address - Phone:313-850-6552
Mailing Address - Fax:
Practice Address - Street 1:4241 MAPLE ST
Practice Address - Street 2:SUITE 200 D
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3826
Practice Address - Country:US
Practice Address - Phone:313-584-1940
Practice Address - Fax:313-584-1945
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004396363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical