Provider Demographics
NPI:1699050781
Name:GOODMAN, ANDREA MARIE (MSPAS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:MARIE
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:MSPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HOLIDAY LOOP
Mailing Address - Street 2:
Mailing Address - City:TIJERAS
Mailing Address - State:NM
Mailing Address - Zip Code:87059-7896
Mailing Address - Country:US
Mailing Address - Phone:618-697-2082
Mailing Address - Fax:
Practice Address - Street 1:MSC06 3870 1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131
Practice Address - Country:US
Practice Address - Phone:505-277-3136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-20
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004195363A00000X
NMPA2017-0087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1750550067OtherUNIVERSITY OF NEW MEXICO STUDENT HEALTH AND COUNSELING