1689809055 NPI number — MRS. BETHANY LYNN HAGEN BOWLES IDMT

Table of content: MRS. BETHANY LYNN HAGEN BOWLES IDMT (NPI 1689809055)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689809055 NPI number — MRS. BETHANY LYNN HAGEN BOWLES IDMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAGEN BOWLES
Provider First Name:
BETHANY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
IDMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HAGEN
Provider Other First Name:
BETHANY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
IDMT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689809055
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 AMDS UNIT 5267
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AP
Provider Business Mailing Address Postal Code:
96368-5267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
011816117304229
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18 AMDS UNIT 5267
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96368-5267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
011816117304229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2009

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: 1710I1003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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