Provider Demographics
NPI:1174103196
Name:GOH, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:GOH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2501
Mailing Address - Street 2:
Mailing Address - City:TUBA CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86045-2501
Mailing Address - Country:US
Mailing Address - Phone:928-640-1118
Mailing Address - Fax:928-433-3757
Practice Address - Street 1:337 LOLOMA ST
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045-0015
Practice Address - Country:US
Practice Address - Phone:928-283-4771
Practice Address - Fax:928-433-3757
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ380918251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health