Provider Demographics
NPI:1962586636
Name:GODWIN, DAVID A (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:A
Last Name:GODWIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 DEER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0012
Mailing Address - Country:US
Mailing Address - Phone:903-832-5630
Mailing Address - Fax:
Practice Address - Street 1:5508 DEER CREEK DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0012
Practice Address - Country:US
Practice Address - Phone:903-832-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04038363A00000X
ARPA179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXS72604Medicare UPIN
TX53407P045Medicare ID - Type Unspecified