Provider Demographics
NPI:1932366028
Name:GODWIN, ANITA HOPKINS (PAC)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:HOPKINS
Last Name:GODWIN
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 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:704-867-2134
Practice Address - Street 1:1875 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7413
Practice Address - Country:US
Practice Address - Phone:704-874-0600
Practice Address - Fax:704-865-4785
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01294363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1932366028Medicaid