Provider Demographics
NPI:1588671283
Name:GOODWIN, BETSY R (PA)
Entity Type:Individual
Prefix:
First Name:BETSY
Middle Name:R
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:STE 440
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3551
Mailing Address - Country:US
Mailing Address - Phone:719-557-4744
Mailing Address - Fax:719-557-4770
Practice Address - Street 1:110 E ROUTT
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004
Practice Address - Country:US
Practice Address - Phone:719-543-8711
Practice Address - Fax:719-543-5340
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07060007Medicaid