Basic Information
| Provider Information | |||||||||
| NPI: | 1518192467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOWAN | ||||||||
| FirstName: | JOZIA | ||||||||
| MiddleName: | COLEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LUTACKAS | ||||||||
| OtherFirstName: | JOZIA | ||||||||
| OtherMiddleName: | COLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5844 NW BARRY RD | ||||||||
| Address2: | STE 270 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641541465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168802600 | ||||||||
| FaxNumber: | 8168802640 | ||||||||
| Practice Location | |||||||||
| Address1: | 5844 NW BARRY RD | ||||||||
| Address2: | STE 270 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641541465 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8168802600 | ||||||||
| FaxNumber: | 8168802640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2009 | ||||||||
| LastUpdateDate: | 01/02/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101018158 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MO2012035077 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.