Provider Demographics
NPI:1548512767
Name:GOODWIN, MATTHEW TROY (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TROY
Last Name:GOODWIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3200 MACCORKLE AVENUE SE
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-388-4172
Mailing Address - Fax:304-388-4155
Practice Address - Street 1:419 EARL RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-6700
Practice Address - Country:US
Practice Address - Phone:704-481-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07095363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV2112AMedicare PIN