Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | NY |
NPI | 1285236661 |
---|---|
Provider Name | Bruce S Goodman I |
First Address | Selden, NY 11784-2532 |
Second Address | Selden, NY 11784-2532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2020 |
Last Update Date | 11/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00615045 | (05) | NY |