Provider Demographics
NPI:1821611732
Name:MCGOWAN, KATHRYN MAE (MSPAS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:MAE
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:MSPAS, PA-C
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Other - First Name:
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Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:4075 COPPER RIDGE DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7059
Practice Address - Country:US
Practice Address - Phone:337-609-5144
Practice Address - Fax:337-573-6224
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-26
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110007447363A00000X
TN4255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant