MEDICARE: DOMINIQUE GOODWIN PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	032438	NY

General Provider Information

NPI Number	:	1598503872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOMINIQUE GOODWIN PA

Provider Business Mailing Address
First Line	:	135 MINEOLA BLVD FL 2
Second Line	:
City	:	MINEOLA
State	:	NY
Zip	:	11501-3917
Country	:	US
Telephone Number	:	917-310-3371
Fax Number	:	516-938-1554

Provider Business Practice Location Address
First Line	:	3007 36TH AVE STE A
Second Line	:
City	:	ASTORIA
State	:	NY
Zip	:	11106-2314
Country	:	US
Telephone Number	:	917-310-3371
Fax Number	:	516-938-1554

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2024
Last Update Date	:	12/12/2025

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Directions to “ DOMINIQUE GOODWIN PA” Practice Location

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