Provider Demographics
NPI:1265756696
Name:GOWAN, LISA P (CNM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:P
Last Name:GOWAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 JOHNTOWN RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-7517
Mailing Address - Country:US
Mailing Address - Phone:334-237-4644
Mailing Address - Fax:
Practice Address - Street 1:104 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6902
Practice Address - Country:US
Practice Address - Phone:334-671-9445
Practice Address - Fax:334-671-0059
Is Sole Proprietor?:No
Enumeration Date:2010-03-14
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-056034367A00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSO1056034Medicaid