Healthcare Provider Details

I. General information

NPI: 1790479962
Provider Name (Legal Business Name): RILEY GOODWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12955 BOGUS JIM RD
RAPID CITY SD
57702-9703
US

IV. Provider business mailing address

12955 BOGUS JIM RD
RAPID CITY SD
57702-9703
US

V. Phone/Fax

Practice location:
  • Phone: 605-786-5643
  • Fax:
Mailing address:
  • Phone: 605-786-5643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: