Provider Demographics
NPI:1245715747
Name:GOODWIN, AMANDA (COTA)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 RAVINE ST
Mailing Address - Street 2:
Mailing Address - City:EMORY
Mailing Address - State:TX
Mailing Address - Zip Code:75440-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5586
Practice Address - Country:US
Practice Address - Phone:903-455-4618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214317207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine