Provider Demographics
NPI:1194711911
Name:GOFF, KATHLEEN M (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:GOFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2003
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4503
Mailing Address - Country:US
Mailing Address - Phone:315-446-3904
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:4900 BROAD RD
Practice Address - Street 2:CGH POB SUITE 2V
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13215-2265
Practice Address - Country:US
Practice Address - Phone:315-492-5005
Practice Address - Fax:315-492-5324
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330961363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02197771Medicaid
NY02197771Medicaid
S44849Medicare UPIN
CC9054Medicare PIN