1215068143 NPI number — WESLEY T COWAN

Table of content: (NPI 1215068143)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215068143 NPI number — WESLEY T COWAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESLEY T COWAN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215068143
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 510
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE PINE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37890-0510
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1627 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITE PINE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37890-3302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-674-2526
Provider Business Practice Location Address Fax Number:
865-674-6739
Provider Enumeration Date:
03/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COWAN
Authorized Official First Name:
WESLEY
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC AND OWNER
Authorized Official Telephone Number:
865-674-2526

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0000001200 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4411790 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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