Provider Demographics
NPI:1538146733
Name:GOODMAN, MARVIN L (CRNA)
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:L
Last Name:GOODMAN
Suffix:
Gender:M
Credentials:CRNA
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 450816
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0816
Mailing Address - Country:US
Mailing Address - Phone:918-787-8980
Mailing Address - Fax:
Practice Address - Street 1:1310 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5304
Practice Address - Country:US
Practice Address - Phone:918-786-2243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0069405367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100789160AMedicaid
OK$$$$$$$$$1Medicare PIN