Provider Demographics
NPI:1881730612
Name:APPALACHIAN STATE UNIVERSITY
Entity type:Organization
Organization Name:APPALACHIAN STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN EXTENDER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:WINSTON
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:828-262-3100
Mailing Address - Street 1:1351 N PINE RUN RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-6778
Mailing Address - Country:US
Mailing Address - Phone:828-265-8503
Mailing Address - Fax:
Practice Address - Street 1:APPALACHIAN STATE UNIVERSITY
Practice Address - Street 2:STUDENT HEALTH SERVICES
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28608-0001
Practice Address - Country:US
Practice Address - Phone:828-262-3100
Practice Address - Fax:828-262-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900081261QS1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP32534Medicare UPIN