Provider Demographics
NPI:1255400388
Name:GOODRICH, WENDY MONIQUE (PA C)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:MONIQUE
Last Name:GOODRICH
Suffix:
Gender:F
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 1:623 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3042
Mailing Address - Country:US
Mailing Address - Phone:208-882-2011
Mailing Address - Fax:
Practice Address - Street 1:623 S MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2983
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5747363A00000X
IDPA-1297363A00000X
DCPA030391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
018402P75Medicare ID - Type Unspecified