Provider Demographics
NPI:1932216934
Name:GOODWILER, GREGORY G (PA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:G
Last Name:GOODWILER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7500 BARLITE BLVD
Mailing Address - Street 2:STE 311
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1363
Mailing Address - Country:US
Mailing Address - Phone:210-450-4000
Mailing Address - Fax:210-450-4903
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:210-916-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02212363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192131402Medicaid
TX8L11196Medicare PIN