Basic Information
| Provider Information | |||||||||
| NPI: | 1093757999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOWAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLMES | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 600 N SIOUX POINT RD | ||||||||
| Address2: | |||||||||
| City: | DAKOTA DUNES | ||||||||
| State: | SD | ||||||||
| PostalCode: | 570495000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052323332 | ||||||||
| FaxNumber: | 6052320854 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 FUTURES DR | ||||||||
| Address2: | |||||||||
| City: | SOUTH SIOUX CITY | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687763917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024127242 | ||||||||
| FaxNumber: | 7122525920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP000341 | SD | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A091311 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 111952 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1093757999 | 05 | IA | MEDICAID | 1093757999 | 05 | NE | MEDICAID | 1093757999 | 05 | SD | MEDICAID |