Basic Information
| Provider Information | |||||||||
| NPI: | 1831368638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COWAN | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCDONALD | ||||||||
| OtherFirstName: | SHELLEY | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 E HACIENDA AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950086625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 E HACIENDA AVE STE B | ||||||||
| Address2: | |||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950086625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 10/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | A101415 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.