Provider Demographics
NPI:1265427025
Name:GOETZ, JENNIFER E (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:GOETZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-3326
Mailing Address - Fax:215-707-8028
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3326
Practice Address - Fax:215-707-8028
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN32360L163W00000X
PA070024367500000X
PARN323360L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50007108OtherCAPITAL ADVANTAGE
PA1436283OtherHIGHMARK
PA2120741000OtherINDEP. BLUE CROSS
PA1436283OtherKHP CENTRAL
PA82849OtherGEISINGER
PA2120741000OtherINDEP. BLUE CROSS
PA430077840Medicare PIN
PA065616QCYMedicare PIN