Provider Demographics
NPI:1124316674
Name:GOODMAN, ROBERT (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:919 HIDDEN RDG
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-3813
Mailing Address - Country:US
Mailing Address - Phone:469-282-2711
Mailing Address - Fax:469-282-2609
Practice Address - Street 1:3817 S PADRE ISLAND DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78415-2913
Practice Address - Country:US
Practice Address - Phone:361-857-0178
Practice Address - Fax:361-855-4123
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06113363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX286995001Medicaid
TX286995001Medicaid