Provider Demographics
NPI:1578652855
Name:GODBOUT, JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:
Last Name:GODBOUT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 MCCRAY ST STE 231
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-2224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:591 MCCRAY ST STE 231
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-2224
Practice Address - Country:US
Practice Address - Phone:831-636-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACL161ZMedicare PIN