Individual
MR. LEDONTRAE GOODEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
6600 VAN AALST BLVD, FORT MOORE, GA 31905-2102
(916) 385-1006
Mailing address
6600 VAN AALST BLVD BLDG 9250, FORT MOORE, GA 31905-2102
(916) 385-1006
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
—
—
363AM0700X
Medical Physician Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
NONE
NONE
—
Enumeration date
12/28/2019
Last updated
01/22/2024
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