MEDICARE: LUKE HENRY COWELL PTA

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	225200000X	Physical Therapy Assistant	2000166666	MO

General Provider Information

NPI Number	:	1063649218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUKE HENRY COWELL PTA

Provider Business Mailing Address
First Line	:	1102 SHADY LN
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-2652
Country	:	US
Telephone Number	:	573-275-0711
Fax Number	:

Provider Business Practice Location Address
First Line	:	1102 SHADY LN
Second Line	:
City	:	JACKSON
State	:	MO
Zip	:	63755-2652
Country	:	US
Telephone Number	:	573-275-0711
Fax Number	:

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

Provider Enumeration Date	:	06/15/2009
Last Update Date	:	06/15/2009

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