Provider Demographics
NPI:1255823191
Name:GOEN, LAURA LEE RUBY (PA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE RUBY
Last Name:GOEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 CROOKS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-5540
Mailing Address - Country:US
Mailing Address - Phone:248-817-6704
Mailing Address - Fax:
Practice Address - Street 1:1890 CROOKS RD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-5540
Practice Address - Country:US
Practice Address - Phone:248-817-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty