Healthcare Provider Details

I. General information

NPI: 1386600021
Provider Name (Legal Business Name): SUSAN MARIE MCGOWEN PHD, EMT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8817 CHERRY HILLS RD NE
ALBUQUERQUE NM
87111-1030
US

IV. Provider business mailing address

8817 CHERRY HILLS RD NE
ALBUQUERQUE NM
87111-1030
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-8167
  • Fax: 505-277-6227
Mailing address:
  • Phone: 505-277-8167
  • Fax: 505-277-6227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number274
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: