Provider Demographics
NPI:1518539907
Name:GODDEYNE, MICHAEL CHARLES (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:GODDEYNE
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2900 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-4330
Practice Address - Country:US
Practice Address - Phone:414-489-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5489-23363AS0400X
WI5489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100177796Medicaid