Provider Demographics
NPI:1689695595
Name:COWNOVER, STACI T (PA-C)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:T
Last Name:COWNOVER
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:P O BOX 1000 DEPT 978
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-840-1202
Mailing Address - Fax:901-840-1204
Practice Address - Street 1:76 CAPITAL WAY STE C
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-6866
Practice Address - Country:US
Practice Address - Phone:901-840-1202
Practice Address - Fax:901-840-1204
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1191363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6007036OtherBCBS
TNQ003620Medicaid