Provider Demographics
NPI:1295758993
Name:GOODHART, JOHN F (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:GOODHART
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-3236
Mailing Address - Country:US
Mailing Address - Phone:757-398-2000
Mailing Address - Fax:757-398-2020
Practice Address - Street 1:3636 HIGH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3236
Practice Address - Country:US
Practice Address - Phone:757-398-2000
Practice Address - Fax:757-398-2020
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA011932B74Medicare PIN