Provider Demographics
NPI:1922860972
Name:GOODMAN, NETANYA (PA)
Entity type:Individual
Prefix:
First Name:NETANYA
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5880 49TH ST N STE 104
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2142
Mailing Address - Country:US
Mailing Address - Phone:727-528-6100
Mailing Address - Fax:727-528-7895
Practice Address - Street 1:5880 49TH ST N STE N104
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2150
Practice Address - Country:US
Practice Address - Phone:727-528-6100
Practice Address - Fax:727-528-7895
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-25
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1213893000Medicaid