Provider Demographics
NPI:1861114373
Name:ORENTAITE, GODA (PA-C)
Entity type:Individual
Prefix:
First Name:GODA
Middle Name:
Last Name:ORENTAITE
Suffix:
Gender:F
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 1:9760 S KEDZIE AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3184
Mailing Address - Country:US
Mailing Address - Phone:708-423-6209
Mailing Address - Fax:
Practice Address - Street 1:9760 S KEDZIE AVE STE 3
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3184
Practice Address - Country:US
Practice Address - Phone:708-423-6209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty