Provider Demographics
NPI:1407907371
Name:MCGOWAN, MAXINE (MSN, PHD, FNP-C)
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:MSN, PHD, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6571 YARBROUGH DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-4649
Mailing Address - Country:US
Mailing Address - Phone:678-343-1257
Mailing Address - Fax:770-306-8720
Practice Address - Street 1:3866 AUGUSTINE PL
Practice Address - Street 2:
Practice Address - City:REX
Practice Address - State:GA
Practice Address - Zip Code:30273-5822
Practice Address - Country:US
Practice Address - Phone:678-343-1257
Practice Address - Fax:770-507-2352
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR07760600363L00000X
GARN201165363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8482306Medicaid
NJ054243Medicare PIN