Provider Demographics
NPI:1821122243
Name:GOODWILL, DERRICK D (MS, PA-C)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:D
Last Name:GOODWILL
Suffix:
Gender:M
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 LAKESIDE PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4226
Mailing Address - Country:US
Mailing Address - Phone:281-491-0413
Mailing Address - Fax:
Practice Address - Street 1:1935 LAKESIDE PLAZA DR
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-4226
Practice Address - Country:US
Practice Address - Phone:281-491-0413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04820363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical