Provider Demographics
NPI:1205166519
Name:COWAN, KIMBERLY LYNN (CRNA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:COWAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WINTER DR
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30560-8210
Mailing Address - Country:US
Mailing Address - Phone:706-374-0408
Mailing Address - Fax:
Practice Address - Street 1:2855 OLD HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-6248
Practice Address - Country:US
Practice Address - Phone:706-632-3711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-08
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9189783367500000X
GA237082367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA2021437602OtherMEDICARE ID - UNION GENERAL HOSPITAL
GA202I432222OtherMEDICARE ID- GEORGIA ANESTHESIA PARTNERS, LLC
GA202I436726OtherMEDICARE ID- AHP OF CENTRAL GEORGIA, PC