Provider Demographics
NPI:1194057729
Name:GOFORTH, EMILY PRICE (PA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:PRICE
Last Name:GOFORTH
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 1:534 WOODS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-2778
Mailing Address - Country:US
Mailing Address - Phone:864-720-2739
Mailing Address - Fax:864-720-2740
Practice Address - Street 1:534 WOODS LAKE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-2778
Practice Address - Country:US
Practice Address - Phone:864-720-2739
Practice Address - Fax:864-720-2740
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1110PAMedicaid
SC1110PAMedicaid