Healthcare Provider Details

I. General information

NPI: 1699023499
Provider Name (Legal Business Name): MARIA ANTONINA MCGOWAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2012
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 MOUNTAIN VIEW DR STE 300
COLCHESTER VT
05446-5988
US

IV. Provider business mailing address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-0192
  • Fax: 802-860-4919
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0550030608
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: