Provider Demographics
NPI:1285175521
Name:GOODHART, TERI RENE (PA-C)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:RENE
Last Name:GOODHART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:RENE
Other - Last Name:MCCORMICK-GOODHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:735 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-4451
Mailing Address - Country:US
Mailing Address - Phone:540-239-6186
Mailing Address - Fax:540-443-9362
Practice Address - Street 1:3700 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-7017
Practice Address - Country:US
Practice Address - Phone:540-951-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant