Provider Demographics
NPI:1457389660
Name:GOODEN, BRENT E (NP)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:E
Last Name:GOODEN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2035 FORT WORTH HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-4782
Mailing Address - Country:US
Mailing Address - Phone:817-594-0496
Mailing Address - Fax:817-599-6533
Practice Address - Street 1:2035 FORT WORTH HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-4782
Practice Address - Country:US
Practice Address - Phone:817-594-0496
Practice Address - Fax:817-599-6533
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9841OtherBCBS
TX092535606Medicaid
TXP00997516Medicare PIN
TXTXB134020Medicare PIN
TXP19477Medicare UPIN