Healthcare Provider Details

I. General information

NPI: 1043015811
Provider Name (Legal Business Name): RYAN GOODWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/17/2025
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 PHILADELPHIA PIKE
CLAYMONT DE
19703-2568
US

IV. Provider business mailing address

2714 PHILADELPHIA PIKE
CLAYMONT DE
19703-2568
US

V. Phone/Fax

Practice location:
  • Phone: 302-408-7310
  • Fax: 302-416-4817
Mailing address:
  • Phone: 302-408-7310
  • Fax: 302-416-4817

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJ2-0011489
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: