Healthcare Provider Details

I. General information

NPI: 1598503872
Provider Name (Legal Business Name): DOMINIQUE GOODWIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2024
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 36TH AVE STE A
ASTORIA NY
11106-2314
US

IV. Provider business mailing address

135 MINEOLA BLVD FL 2
MINEOLA NY
11501-3917
US

V. Phone/Fax

Practice location:
  • Phone: 917-310-3371
  • Fax: 516-938-1554
Mailing address:
  • Phone: 917-310-3371
  • Fax: 516-938-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032438
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: