Provider Demographics
NPI:1063536670
Name:GODFREY, NOREEN M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:NOREEN
Middle Name:M
Last Name:GODFREY
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 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:608 S 9TH ST STE C
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6342
Practice Address - Country:US
Practice Address - Phone:813-321-1786
Practice Address - Fax:813-321-1787
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA2766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL970029285OtherMEDICARE RR
FLE1495VMedicare ID - Type Unspecified
FLS65933Medicare UPIN