Provider Demographics
NPI:1457406241
Name:GODBOULDT, BEATRICE LEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BEATRICE
Middle Name:LEE
Last Name:GODBOULDT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 98978
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89193-8978
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:821 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5339
Practice Address - Country:US
Practice Address - Phone:702-438-4003
Practice Address - Fax:702-438-0555
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12936207P00000X, 363A00000X
NVPA1710363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1457406241Medicaid
CAW809FMedicare ID - Type UnspecifiedEL MONTE
CAW932Medicare ID - Type UnspecifiedHEALTH CENTER
CAW809BMedicare ID - Type UnspecifiedHUDSON
NVPENDINGMedicare PIN
CAW809AMedicare ID - Type UnspecifiedROYBAL