Basic Information
| Provider Information | |||||||||
| NPI: | 1447875406 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOWA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE GENESYS PKWY | ||||||||
| Address2: | GME DEPT | ||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48439 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE GENESYS PKWY | ||||||||
| Address2: | GME DEPT | ||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106065000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 06/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 5151014699 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.