Provider Demographics
NPI:1912468315
Name:COWAN, MICHAEL (PTA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COWAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3865 N PRESTON AVE
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-1350
Mailing Address - Country:US
Mailing Address - Phone:904-607-9551
Mailing Address - Fax:
Practice Address - Street 1:984 N MERIDIAN PL
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7215
Practice Address - Country:US
Practice Address - Phone:907-631-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK140245225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant