Provider Demographics
NPI:1902989544
Name:GOODRICH, DAVID MARKUS (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MARKUS
Last Name:GOODRICH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2828
Mailing Address - Country:US
Mailing Address - Phone:719-543-7877
Mailing Address - Fax:719-543-7882
Practice Address - Street 1:1218 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2828
Practice Address - Country:US
Practice Address - Phone:719-543-7877
Practice Address - Fax:719-543-7882
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN12279367500000X
TNRN99907367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3636921Medicaid
TN4137595OtherBCBS OF TN
P00371821OtherRAILROAD MEDICARE
TN3636921Medicaid