Provider Demographics
NPI:1487159976
Name:GOODWIN, CHRISTA CHEYENNE (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTA
Middle Name:CHEYENNE
Last Name:GOODWIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CHRISTA
Other - Middle Name:CHEYENNE
Other - Last Name:MCKAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1103 S US HIGHWAY 169
Mailing Address - Street 2:
Mailing Address - City:SMITHVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64089-9322
Mailing Address - Country:US
Mailing Address - Phone:816-691-5340
Mailing Address - Fax:816-346-7054
Practice Address - Street 1:1103 S US HIGHWAY 169
Practice Address - Street 2:
Practice Address - City:SMITHVILLE
Practice Address - State:MO
Practice Address - Zip Code:64089-9322
Practice Address - Country:US
Practice Address - Phone:816-691-5340
Practice Address - Fax:816-346-7054
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018020725207Q00000X
390200000X
MO2020038020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1487159976Medicaid