Healthcare Provider Details

I. General information

NPI: 1497395206
Provider Name (Legal Business Name): AMANDA MICHELLE COWAN AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10624 S EASTERN AVE # A-955
HENDERSON NV
89052-2982
US

IV. Provider business mailing address

820 SAN GABRIEL AVE
HENDERSON NV
89002
US

V. Phone/Fax

Practice location:
  • Phone: 702-800-5393
  • Fax: 702-407-7016
Mailing address:
  • Phone: 702-985-2685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number828374
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number21468
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: