Provider Demographics
NPI:1023099637
Name:GOOD, JULIAN (FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:JULIAN
Middle Name:
Last Name:GOOD
Suffix:
Gender:M
Credentials:FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2760
Mailing Address - Country:US
Mailing Address - Phone:330-763-2936
Mailing Address - Fax:307-637-6852
Practice Address - Street 1:510 W 29TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2760
Practice Address - Country:US
Practice Address - Phone:330-763-2936
Practice Address - Fax:307-637-6852
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY19109.0857363LF0000X, 363LP0808X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY123919800Medicaid
WY123919800Medicaid
WY21133Medicare PIN