Provider Demographics
NPI:1295118446
Name:GOEDERT, JOHN JOSEPH III (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JOSEPH
Last Name:GOEDERT
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-691-8070
Mailing Address - Fax:270-691-8026
Practice Address - Street 1:1200 BARRETT BLVD
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-4950
Practice Address - Country:US
Practice Address - Phone:270-844-8600
Practice Address - Fax:270-844-8610
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001845A363A00000X
KYTC699363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYPENDINGMedicaid