Basic Information
| Provider Information | |||||||||
| NPI: | 1124016399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOODWIN | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 1236 E ELIZABETH ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805244000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702242985 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 02/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 121533 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 52909361 | 05 | CO | MEDICAID | 117082100 | 05 | WY | MEDICAID |