Individual
MICHAEL CHARLES GODDEYNE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2900 W OKLAHOMA AVE, MILWAUKEE, WI 53215-4330
(414) 489-4190
Mailing address
PO BOX 735044, CHICAGO, IL 60673-5044
(800) 326-2250
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
5489
WI
363AS0400X
Surgical Physician Assistant
5489-23
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100177796
—
WI
Enumeration date
07/14/2021
Last updated
08/12/2024
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