1609011261 NPI number — MRS. CRYSTAL D COWAN FNP-BC

Table of content: MRS. CRYSTAL D COWAN FNP-BC (NPI 1609011261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609011261 NPI number — MRS. CRYSTAL D COWAN FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COWAN
Provider First Name:
CRYSTAL
Provider Middle Name:
D
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TYMUS
Provider Other First Name:
CRYSTAL
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP-BC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609011261
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 SPRING VALLEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURLINGTON
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53105-7614
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:
709 SPRING VALLEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53105-7614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-767-6000
Provider Business Practice Location Address Fax Number:
262-767-6000
Provider Enumeration Date:
12/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 364SP0200X , with the licence number:  3599 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: 3599-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1609011261 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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