Provider Demographics
NPI:1457932964
Name:GOODMAN, SHELBY DORIS
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:DORIS
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHELBY
Other - Middle Name:DORIS
Other - Last Name:ROSSOW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-312-9802
Practice Address - Street 1:700 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1802
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-4134
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR39844363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner