Provider Demographics
NPI:1013764984
Name:GOODWIN, SARA (NP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8233 GLENCARIN BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5784
Practice Address - Country:US
Practice Address - Phone:260-425-5470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28252299A163WP2201X
IN71015409A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care