Provider Demographics
NPI:1538719026
Name:GOODWIN, KYRSTINA GRACE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KYRSTINA
Middle Name:GRACE
Last Name:GOODWIN
Suffix:
Gender:F
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 1:2529 CAT CAY LN
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4753
Mailing Address - Country:US
Mailing Address - Phone:954-253-7886
Mailing Address - Fax:
Practice Address - Street 1:7007 W BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-2208
Practice Address - Country:US
Practice Address - Phone:954-791-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant