Provider Demographics
NPI:1184493769
Name:GOODRICK, IAN BENJAMIN (DNP-A, CRNA)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:BENJAMIN
Last Name:GOODRICK
Suffix:
Gender:M
Credentials:DNP-A, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5473 BLAIR RD STE 100 PMB 760375
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4227
Mailing Address - Country:US
Mailing Address - Phone:281-908-1179
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-742-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-25
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX953739367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty