Provider Demographics
NPI:1457998320
Name:GOENAGA, DESIREE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DESIREE
Middle Name:
Last Name:GOENAGA
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 1:251 E BRINGHURST ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1799
Mailing Address - Country:US
Mailing Address - Phone:215-844-1020
Mailing Address - Fax:215-844-2702
Practice Address - Street 1:1003 MAIN AVE STE 101
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2333
Practice Address - Country:US
Practice Address - Phone:973-928-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061236363A00000X
NJ25MP00548400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant