Basic Information
Provider Information | |||||||||
NPI: | 1295994549 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COWAN | ||||||||
FirstName: | CRAIG | ||||||||
MiddleName: | BRUCE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | II | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2222 N NEVADA AVE | ||||||||
Address2: |   | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809076819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7194750299 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 170 N 1100 E | ||||||||
Address2: |   | ||||||||
City: | AMERICAN FORK | ||||||||
State: | UT | ||||||||
PostalCode: | 840032961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8018554600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/03/2008 | ||||||||
LastUpdateDate: | 09/03/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N0708 | TX | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 390200000X | N0708 | TX | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | 377898-1204 | UT | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
No ID Information.