Healthcare Provider Details

I. General information

NPI: 1013433036
Provider Name (Legal Business Name): TIRAS GOODWIN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10154 117TH ST
SOUTH RICHMOND HILL NY
11419-1906
US

IV. Provider business mailing address

14202 20TH AVE
FLUSHING NY
11351-3000
US

V. Phone/Fax

Practice location:
  • Phone: 718-846-4007
  • Fax:
Mailing address:
  • Phone: 718-559-0516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408817
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: