Provider Demographics
NPI:1043309669
Name:GOODWIN, GREGORY WAYNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:WAYNE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:1269 US HIGHWAY 221A
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-5921
Mailing Address - Country:US
Mailing Address - Phone:828-657-5371
Mailing Address - Fax:828-657-9190
Practice Address - Street 1:1269 US HIGHWAY 221A
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-5921
Practice Address - Country:US
Practice Address - Phone:828-657-5371
Practice Address - Fax:828-657-9190
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC102644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP22111Medicare UPIN