Provider Demographics
NPI:1316129901
Name:MCGOWAN, KATHERINE A (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4331 N SACRAMENTO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-1471
Mailing Address - Country:US
Mailing Address - Phone:773-251-1043
Mailing Address - Fax:
Practice Address - Street 1:675 N SAINT CLAIR ST
Practice Address - Street 2:SUITE 19-100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5975
Practice Address - Country:US
Practice Address - Phone:312-695-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006657363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00795374Medicare PIN
IL218740005Medicare PIN
ILK48173Medicare PIN