Provider Demographics
NPI:1861758187
Name:GOODRICH, KATHERINE ANNE (PA-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:GOODRICH
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 1:242 HUNTLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-2988
Mailing Address - Country:US
Mailing Address - Phone:317-201-0973
Mailing Address - Fax:
Practice Address - Street 1:242 HUNTLEY AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-2988
Practice Address - Country:US
Practice Address - Phone:317-201-0973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004652363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVE238AMedicare PIN
VAP01477721Medicare PIN