Provider Demographics
NPI:1558674382
Name:GOODWIN, MICHAEL EUGENE (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 W RAY RD
Mailing Address - Street 2:#4-508
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2065
Mailing Address - Country:US
Mailing Address - Phone:480-225-2117
Mailing Address - Fax:
Practice Address - Street 1:4939 W RAY RD
Practice Address - Street 2:#4-508
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2065
Practice Address - Country:US
Practice Address - Phone:480-225-2117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1022363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical