Basic Information
Provider Information | |||||||||
NPI: | 1093919896 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COWAN | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 843298 | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 022843298 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9108785100 | ||||||||
FaxNumber: | 9108785100 | ||||||||
Practice Location | |||||||||
Address1: | 4565 FAYETTEVILLE ROAD | ||||||||
Address2: | SUITE A | ||||||||
City: | RAEFORD | ||||||||
State: | NC | ||||||||
PostalCode: | 283760000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9108785100 | ||||||||
FaxNumber: | 9108785140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2007 | ||||||||
LastUpdateDate: | 03/11/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2010-01286 | NC | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5915388 | 05 | NC |   | MEDICAID |