Basic Information
| Provider Information | |||||||||
| NPI: | 1912311259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOOD | ||||||||
| FirstName: | KATELYN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4105 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 3851 PIPER STREET | ||||||||
| Address2: | SUITE U TOWER LL002 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072127997 | ||||||||
| FaxNumber: | 9072128225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2014 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 125064614 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0002X | 036.146126 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 207RH0002X | 147791 | AK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine | 208000000X | 125064614 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1697207 | 05 | AK | MEDICAID |