MEDICARE: MR. THOMAS FANCIS GOWEN JR. RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WN0300X	Nephrology Registered Nurse	136999	MO

General Provider Information

NPI Number	:	1336897370
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS FANCIS GOWEN JR. RN

Provider Business Mailing Address
First Line	:	7710 ELTON ST
Second Line	:
City	:	GRANTWOOD VLG
State	:	MO
Zip	:	63123-3806
Country	:	US
Telephone Number	:	314-598-2867
Fax Number	:

Provider Business Practice Location Address
First Line	:	272 MAYFAIR PLAZA SHOPPING CTR
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-8009
Country	:	US
Telephone Number	:	314-859-1234
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2022
Last Update Date	:	03/17/2022

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