Provider Demographics
NPI:1386914828
Name:MCGOWAN, MICHAEL C (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:MCGOWAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 AMHURST ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2868
Mailing Address - Country:US
Mailing Address - Phone:601-720-1116
Mailing Address - Fax:
Practice Address - Street 1:400 E POLK ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353
Practice Address - Country:US
Practice Address - Phone:319-653-5481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012003064367500000X
IAD141888367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered