Provider Demographics
NPI:1588327258
Name:GOODRICH, NATHAN (IDHS)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:IDHS
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 486
Mailing Address - Street 2:
Mailing Address - City:VALDEZ
Mailing Address - State:AK
Mailing Address - Zip Code:99686-0486
Mailing Address - Country:US
Mailing Address - Phone:907-835-7257
Mailing Address - Fax:
Practice Address - Street 1:105 CLIFTON AVE.
Practice Address - Street 2:
Practice Address - City:VALDEZ
Practice Address - State:AK
Practice Address - Zip Code:99686
Practice Address - Country:US
Practice Address - Phone:907-835-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman