Provider Demographics
NPI:1427197920
Name:GOODWIN, GREGORY THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:THOMAS
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9024 SNIKTAW LN
Mailing Address - Street 2:
Mailing Address - City:FORT JONES
Mailing Address - State:CA
Mailing Address - Zip Code:96032-9408
Mailing Address - Country:US
Mailing Address - Phone:530-468-4470
Mailing Address - Fax:530-468-4478
Practice Address - Street 1:9024 SNIKTAW LN
Practice Address - Street 2:
Practice Address - City:FORT JONES
Practice Address - State:CA
Practice Address - Zip Code:96032-9408
Practice Address - Country:US
Practice Address - Phone:530-468-4470
Practice Address - Fax:530-468-4478
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14029363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical