Basic Information
| Provider Information | |||||||||
| NPI: | 1356098271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODSON | ||||||||
| FirstName: | BOBBY | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | SRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 162 MARCUS WAY APT 3 | ||||||||
| Address2: | |||||||||
| City: | ABINGDON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242104177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2766962657 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 N STATE OF FRANKLIN RD | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376046035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234316111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2022 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WS0200X | 0001265704 | VA | Y | Nursing Service Providers | Registered Nurse | School |
No ID Information.