Provider Demographics
NPI:1770170672
Name:GOWANS, COLLEEN (NP-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:GOWANS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 281490
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1490
Mailing Address - Country:US
Mailing Address - Phone:801-771-7717
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S STE 3100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-262-2806
Practice Address - Fax:801-262-2023
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7538941-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1689721219Medicaid