Provider Demographics
NPI:1003807884
Name:COWAN, LISA MAE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MAE
Last Name:COWAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19260 SW 65TH AVE
Mailing Address - Street 2:STE 270
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-5705
Mailing Address - Country:US
Mailing Address - Phone:503-885-9391
Mailing Address - Fax:503-563-5520
Practice Address - Street 1:19260 SW 65TH AVE STE 270
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-885-9391
Practice Address - Fax:503-563-5520
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R113018OtherMEDICARE PTAN
OR215608Medicaid
ORP57863Medicare UPIN