Basic Information
| Provider Information | |||||||||
| NPI: | 1053450387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | JOANN | ||||||||
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| Credential: | AA | ||||||||
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| OtherLastName: | BRENNAN | ||||||||
| OtherFirstName: | JOANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 804 SCOTT NIXON MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309072464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003944445 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 MALL BLVD | ||||||||
| Address2: | STE T | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064861 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123557214 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2007 | ||||||||
| LastUpdateDate: | 03/20/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001492 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 367H00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
No ID Information.