Healthcare Provider Details

I. General information

NPI: 1902314461
Provider Name (Legal Business Name): BRANDT GOODWIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2018
Last Update Date: 01/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 E MARSHALL AVE
LONGVIEW TX
75601-5580
US

IV. Provider business mailing address

2076 YASMEEN CIR
FLINT TX
75762-6735
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-2000
  • Fax:
Mailing address:
  • Phone: 903-754-2384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number119809
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: