Provider Demographics
NPI:1316159429
Name:GOLDBAUM, ROSS (PA-C)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:GOLDBAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 BLUE RIDGE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6478
Mailing Address - Country:US
Mailing Address - Phone:919-784-5650
Mailing Address - Fax:
Practice Address - Street 1:2800 BLUE RIDGE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6478
Practice Address - Country:US
Practice Address - Phone:919-784-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2746755AMedicare PIN
NC2746755Medicare ID - Type UnspecifiedPROVIDER NUMBER