Provider Demographics
NPI:1396754404
Name:GOODWIN, AMANDA M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:M
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:M
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5483 GRATIOT ROAD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48638-6037
Mailing Address - Country:US
Mailing Address - Phone:989-799-5557
Mailing Address - Fax:989-799-2840
Practice Address - Street 1:5483 GRATIOT ROAD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48638-6037
Practice Address - Country:US
Practice Address - Phone:989-799-5557
Practice Address - Fax:989-799-2840
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAG004842363A00000X
MI5601004842363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
200G311050OtherBCBS GROUP
200G311050OtherBCBS GROUP
Q72456Medicare UPIN
MI0N83160004Medicare ID - Type Unspecified