Basic Information
| Provider Information | |||||||||
| NPI: | 1881095610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGOWAN | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MUMFORD | ||||||||
| OtherFirstName: | CAITLIN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 230 PROSPECT PL STE 340B | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921181991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195224000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 230 PROSPECT PL STE 340B | ||||||||
| Address2: | |||||||||
| City: | CORONADO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921181991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195224000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2014 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110005369 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 58460 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.