Provider Demographics
NPI:1770514689
Name:GOODALE, JEFFREY L (PA-C)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:L
Last Name:GOODALE
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26922 OSO PKWY
Mailing Address - Street 2:SUITE 380
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5800
Mailing Address - Country:US
Mailing Address - Phone:949-582-5430
Mailing Address - Fax:949-348-9513
Practice Address - Street 1:26922 OSO PKWY
Practice Address - Street 2:SUITE 380
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5800
Practice Address - Country:US
Practice Address - Phone:949-582-5430
Practice Address - Fax:949-348-9513
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
G74763Medicare ID - Type Unspecified