Provider Demographics
NPI:1124504352
Name:MCGOWAN, THOMAS HAROLD (MED, ATC, LAT)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:HAROLD
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:
Other - Last Name:MCGOWAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, ATC, LAT
Mailing Address - Street 1:8637 BROOKSHIRE LN APT C
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-4711
Mailing Address - Country:US
Mailing Address - Phone:314-437-6433
Mailing Address - Fax:
Practice Address - Street 1:13001 N OUTER 40 RD STE 2A
Practice Address - Street 2:
Practice Address - City:TOWN AND COUNTRY
Practice Address - State:MO
Practice Address - Zip Code:63017-5941
Practice Address - Country:US
Practice Address - Phone:314-324-0367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20130036732255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer