Provider Demographics
NPI:1750445979
Name:MACGOWAN, DAMIANN
Entity Type:Individual
Prefix:
First Name:DAMIANN
Middle Name:
Last Name:MACGOWAN
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 1:16 CHEMUNG PL
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-1502
Mailing Address - Country:US
Mailing Address - Phone:516-470-0985
Mailing Address - Fax:
Practice Address - Street 1:16 CHEMUNG PL
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-1502
Practice Address - Country:US
Practice Address - Phone:516-470-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051256363A00000X
NY012587-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant