Provider Demographics
NPI:1073819470
Name:GOLDBERG, RACHEL ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:ANN
Last Name:GOLDBERG
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 1:9400 ZANE AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1814
Mailing Address - Country:US
Mailing Address - Phone:763-762-8800
Mailing Address - Fax:763-315-4669
Practice Address - Street 1:9400 ZANE AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1814
Practice Address - Country:US
Practice Address - Phone:763-762-8800
Practice Address - Fax:763-315-4669
Is Sole Proprietor?:No
Enumeration Date:2011-02-02
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12161363A00000X
NY014522-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03334109Medicaid
NYJ900048775Medicare PIN