Provider Demographics
NPI:1841285608
Name:GODSHALL, THERESA M (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:GODSHALL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:1245 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9099
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN241001L163W00000X
PA039848367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1368657OtherKHP CENTRAL
PA206043000OtherINDEP. BLUE CROSS
PA1027820420001Medicaid
PA11783674OtherCAQH
PA9417489OtherAETNA
PA1368657OtherFIRST PRIORITY
PA1544545OtherGATEWAY
PA1368657OtherHIGHMARK
PA76023OtherGEISINGER
PA03222701OtherCAPITAL ADVANTAGE
PA1368657OtherHIGHMARK
PAS57956Medicare UPIN
PA430070726Medicare PIN