Provider Demographics
NPI:1164405403
Name:COWAN, RUSSELL C (PA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:C
Last Name:COWAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W OLLIE ST
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-2628
Mailing Address - Country:US
Mailing Address - Phone:325-247-5040
Mailing Address - Fax:325-248-2801
Practice Address - Street 1:2112 HWY 1431
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:TX
Practice Address - Zip Code:78639-6010
Practice Address - Country:US
Practice Address - Phone:325-388-3515
Practice Address - Fax:325-388-9417
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB127264Medicare PIN
TX8398K7Medicare PIN
P36330Medicare UPIN