Provider Demographics
NPI:1164735494
Name:COWGILL, JEREMY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:LEE
Last Name:COWGILL
Suffix:
Gender:M
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 1:7450 KESSLER ST STE 140
Mailing Address - Street 2:
Mailing Address - City:MERRIAM
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2519
Mailing Address - Country:US
Mailing Address - Phone:913-362-8317
Mailing Address - Fax:913-362-0169
Practice Address - Street 1:7450 KESSLER ST STE 140
Practice Address - Street 2:
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2519
Practice Address - Country:US
Practice Address - Phone:913-362-8317
Practice Address - Fax:913-362-0169
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01380363A00000X
KS1501380363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200674450CMedicaid
KS200674450CMedicaid