Basic Information
| Provider Information | |||||||||
| NPI: | 1164406526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOEN | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | SUITE 3A112 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432373 | ||||||||
| FaxNumber: | 8067434354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | SA0039 | TX | Y |
ID Information
| ID | Type | State | Issuer | Description | A600 | 01 | NM | TRIWEST | OTHER | 89N940 | 01 | TX | HMO BLUE | OTHER | 89N938 | 01 | TX | BC/BS | OTHER |