Provider Demographics
NPI:1356570576
Name:GODDARD, AMANDA R (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:GODDARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:R
Other - Last Name:BARGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3808 S GREYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-6561
Mailing Address - Country:US
Mailing Address - Phone:417-889-3332
Mailing Address - Fax:417-881-1410
Practice Address - Street 1:3808 S GREYSTONE CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6561
Practice Address - Country:US
Practice Address - Phone:417-889-3332
Practice Address - Fax:417-881-1410
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009018151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
MOP00985991OtherRR MCR
MO8P159OtherARKANSAS BLUECROSS/BLUE SHIELD
MO8P159OtherARKANSAS BLUECROSS/BLUE SHIELD
MOP00985991OtherRR MCR