Provider Demographics
NPI:1497128540
Name:MCGOWAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 72ND AVE NE
Mailing Address - Street 2:APT 106
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-3561
Mailing Address - Country:US
Mailing Address - Phone:763-607-5188
Mailing Address - Fax:
Practice Address - Street 1:25 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1568
Practice Address - Country:US
Practice Address - Phone:763-682-3005
Practice Address - Fax:763-682-3006
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN224477-0163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse