Provider Demographics
NPI:1093881393
Name:GOODWIN, AMANDA JACKSON (PAC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JACKSON
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-1309
Mailing Address - Country:US
Mailing Address - Phone:859-238-5530
Mailing Address - Fax:859-238-5380
Practice Address - Street 1:600 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1309
Practice Address - Country:US
Practice Address - Phone:859-238-5530
Practice Address - Fax:859-238-5380
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical