Provider Demographics
NPI:1073246203
Name:GOODRUM, HANNAH LEIGH (PA-C)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:LEIGH
Last Name:GOODRUM
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 1:3024 NEW BERN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1247
Mailing Address - Country:US
Mailing Address - Phone:919-350-7331
Mailing Address - Fax:
Practice Address - Street 1:210 ASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6676
Practice Address - Country:US
Practice Address - Phone:919-350-9355
Practice Address - Fax:919-851-6757
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-122582086S0102X, 363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1073246203Medicaid