Provider Demographics
NPI:1700356953
Name:MCGOWAN, ANGELICA LILIANA (PA)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:LILIANA
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ANGELICA
Other - Middle Name:LILIANA
Other - Last Name:FORERO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:271 GLEN IRIS DR NE APT A2
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1476
Mailing Address - Country:US
Mailing Address - Phone:678-549-3737
Mailing Address - Fax:
Practice Address - Street 1:2213 EXCHANGE PL SE STE A
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6723
Practice Address - Country:US
Practice Address - Phone:770-483-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9084363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant