Provider Demographics
NPI:1801311543
Name:GODINEZ, ROBERTO (FNP)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:
Last Name:GODINEZ
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 NORWOOD AVE APT 146
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95838-2678
Mailing Address - Country:US
Mailing Address - Phone:323-599-3423
Mailing Address - Fax:
Practice Address - Street 1:344 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3631
Practice Address - Country:US
Practice Address - Phone:559-664-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95029983363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013030808Medicaid