Basic Information
| Provider Information | |||||||||
| NPI: | 1730141987 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODAVISH | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MMS PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANDORF | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MMS PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7974 UW HEALTH CT | ||||||||
| Address2: | |||||||||
| City: | MIDDLETON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535625531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295485 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4602 EASTPARK BLVD | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537182002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082638820 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MED-PAC-LIC-79429 | MT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1933-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.