Provider Demographics
NPI:1205137551
Name:GOODMANSON, SAMANTHA
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GOODMANSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANTIAGO
Other - Middle Name:
Other - Last Name:SANTANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12100 SINGLETREE LN STE 196
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-7961
Mailing Address - Country:US
Mailing Address - Phone:612-746-1341
Mailing Address - Fax:
Practice Address - Street 1:5525 141ST ST N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-8429
Practice Address - Country:US
Practice Address - Phone:612-356-8764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27-0897702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist