Provider Demographics
NPI:1881998177
Name:GOODIN, MARTHA (PA-C)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:GOODIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:MARTHA
Other - Middle Name:GOODIN
Other - Last Name:HETHERWICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Mailing Address - Street 2:SUITE 401
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3133
Mailing Address - Country:US
Mailing Address - Phone:318-686-5440
Mailing Address - Fax:318-686-0624
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP
Practice Address - Street 2:SUITE 401
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3133
Practice Address - Country:US
Practice Address - Phone:318-686-5440
Practice Address - Fax:318-686-0624
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-01
Last Update Date:2011-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL#10350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant