Provider Demographics
NPI:1780691394
Name:GOODMAN, CHRISTINA (PA)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 PIONEER RD APT 1204
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3799
Mailing Address - Country:US
Mailing Address - Phone:208-351-6470
Mailing Address - Fax:
Practice Address - Street 1:100 STUDENT HEALTH CENTER BUILDING
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-496-1300
Practice Address - Fax:208-496-1306
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA591363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDQ59674Medicare UPIN
ID1667352Medicare ID - Type Unspecified