Healthcare Provider Details

I. General information

NPI: 1972449734
Provider Name (Legal Business Name): TRE GOODWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 JUAN TABO BLVD NE STE 2B
ALBUQUERQUE NM
87111-2691
US

IV. Provider business mailing address

21341 RISING FAWN RD
PORTER TX
77365-7632
US

V. Phone/Fax

Practice location:
  • Phone: 346-323-1847
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN322447
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: