Provider Demographics
NPI:1104255496
Name:GOEDTEL, LAUREN (PAC)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GOEDTEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MARLIN AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-1323
Mailing Address - Country:US
Mailing Address - Phone:248-288-4500
Mailing Address - Fax:248-288-1378
Practice Address - Street 1:3577 W 13 MILE RD
Practice Address - Street 2:STE 103
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-288-4500
Practice Address - Fax:248-288-1378
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant