Healthcare Provider Details

I. General information

NPI: 1306880026
Provider Name (Legal Business Name): TAVIS COWAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680NWSAMARITAN DR
CORVALLIS OR
97330-3737
US

IV. Provider business mailing address

444NWELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-754-1150
  • Fax:
Mailing address:
  • Phone: 541-754-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD172092
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number042-0011895
License Number StateVT
# 3
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0420011895
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: