MEDICARE: MAXINE MCGOWAN MSN, PHD, FNP-C

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	363L00000X	Nurse Practitioner	26NR07760600	NJ
2	363LP2300X	Primary Care Nurse Practitioner	RN201165	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407907371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXINE MCGOWAN MSN, PHD, FNP-C

Provider Business Mailing Address
First Line	:	6571 YARBROUGH DR
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-4649
Country	:	US
Telephone Number	:	678-343-1257
Fax Number	:	770-306-8720

Provider Business Practice Location Address
First Line	:	3866 AUGUSTINE PL
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-5822
Country	:	US
Telephone Number	:	678-343-1257
Fax Number	:	770-507-2352

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2013

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