Provider Demographics
NPI:1073796108
Name:GOODBREAD, MICHELE L (PA)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:L
Last Name:GOODBREAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 W RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1746
Mailing Address - Country:US
Mailing Address - Phone:814-835-2580
Mailing Address - Fax:814-835-2590
Practice Address - Street 1:4247 W RIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-1746
Practice Address - Country:US
Practice Address - Phone:814-835-2580
Practice Address - Fax:814-835-2590
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053005363AM0700X
TN1774363AM0700X
PAOA006782363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516442Medicaid
3703867Medicare PIN
3703865Medicare PIN
TN1516442Medicaid