Healthcare Provider Details

I. General information

NPI: 1336738293
Provider Name (Legal Business Name): JONATHAN PERRY GOODWIN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 S 100TH EAST AVE STE 201
TULSA OK
74146-3629
US

IV. Provider business mailing address

4110 S 100TH EAST AVE STE 201
TULSA OK
74146-3629
US

V. Phone/Fax

Practice location:
  • Phone: 918-857-7246
  • Fax: 918-359-5828
Mailing address:
  • Phone: 918-857-7246
  • Fax: 918-359-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201903
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR0129507
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: