Provider Demographics
NPI:1962598367
Name:GOETZ, AMY M (PA-C)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:M
Last Name:GOETZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:M
Other - Last Name:GONZENBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8550 NE 138TH LN STE 102
Mailing Address - Street 2:
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-6816
Mailing Address - Country:US
Mailing Address - Phone:352-325-5555
Mailing Address - Fax:346-202-0106
Practice Address - Street 1:8550 NE 138TH LN STE 102
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-6816
Practice Address - Country:US
Practice Address - Phone:352-325-5555
Practice Address - Fax:346-202-0106
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085002812363AS0400X
FLPA9108881363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085002812Medicaid
IL085002812Medicaid
ILR00147Medicare PIN
IL214881160Medicare PIN
ILK47170Medicare PIN
IL214881Medicare Oscar/Certification
ILK38624Medicare PIN