Provider Demographics
NPI:1902587835
Name:MCGOWAN, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MYRTLE AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-3797
Mailing Address - Country:US
Mailing Address - Phone:518-262-5640
Mailing Address - Fax:
Practice Address - Street 1:391 MYRTLE AVE STE 5
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3797
Practice Address - Country:US
Practice Address - Phone:518-262-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-25
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily