Individual
MRS. STEPHANIE H GOEDE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
420 N IL ROUTE 31, CRYSTAL LAKE, IL 60012
(815) 356-5200
(815) 356-5262
Mailing address
420 N IL ROUTE 31, CRYSTAL LAKE, IL 60012-3709
(815) 356-5200
(815) 356-5262
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
085.004468
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085004468
STATE LICENSE
IL
01
—
1108763
NCCPA
IL
Enumeration date
08/30/2012
Last updated
06/07/2018
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