Basic Information
Provider Information
NPI: 1033558424
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MACGOWAN
FirstName: SANDRA
MiddleName: M
NamePrefix: MRS.
NameSuffix:  
Credential: LMT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 221 AYRAULT RD
Address2:  
City: FAIRPORT
State: NY
PostalCode: 144502855
CountryCode: US
TelephoneNumber: 5857297072
FaxNumber:  
Practice Location
Address1: 221 AYRAULT RD
Address2:  
City: FAIRPORT
State: NY
PostalCode: 144502855
CountryCode: US
TelephoneNumber: 5857297072
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/18/2013
LastUpdateDate: 07/03/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000X27024724NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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