Provider Demographics
NPI:1710999149
Name:GOODWIN, NANCY L (PAC)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:L
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 1:7350 W DESCHUTES AVE
Mailing Address - Street 2:B103
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-783-0144
Mailing Address - Fax:509-783-8244
Practice Address - Street 1:7350 W DESCHUTES AVE
Practice Address - Street 2:B103
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-783-0144
Practice Address - Fax:509-783-8244
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003410363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8324253Medicaid
WA8324253Medicaid
WAS91200Medicare UPIN