Provider Demographics
NPI:1578976619
Name:GOEDHART MEDICAL GROUP
Entity type:Organization
Organization Name:GOEDHART MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEDHART
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:702-682-8155
Mailing Address - Street 1:1320 E CALVADA BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 E CALVADA BOULEVARD
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048
Practice Address - Country:US
Practice Address - Phone:702-682-8155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN000597363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty