Provider Demographics
NPI:1215046768
Name:GOODMAN, GREGORY G (FNP)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:G
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 FARAON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3488
Mailing Address - Country:US
Mailing Address - Phone:816-271-7986
Mailing Address - Fax:816-271-7986
Practice Address - Street 1:5325 FARAON ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3488
Practice Address - Country:US
Practice Address - Phone:816-271-7986
Practice Address - Fax:816-271-7986
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO095469363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200553990CMedicaid
KS200553990BMedicaid
MO425076601Medicaid
MO540492501Medicaid
KS200553990AMedicaid
MO10001503301OtherCOMMUNITY HEALTH PLAN
30405021OtherBCBS
KS200553990DMedicaid
MO10001503301OtherCOMMUNITY HEALTH PLAN
J55000002Medicare PIN