Provider Demographics
NPI:1740258854
Name:GOODWIN, DEBRA P (PAC)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:P
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:PO BOX 1754
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18105-1754
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3691 CRESCENT CT E
Practice Address - Street 2:STE 201
Practice Address - City:WHITEHALL
Practice Address - State:PA
Practice Address - Zip Code:18052-3433
Practice Address - Country:US
Practice Address - Phone:610-434-9561
Practice Address - Fax:610-434-5122
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003213L363A00000X
PAOA000467L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA045703Medicare ID - Type Unspecified
P25679Medicare UPIN