1609878917 NPI number — DR. TRINA BOWEN MD

Table of content: DR. TRINA BOWEN MD (NPI 1609878917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609878917 NPI number — DR. TRINA BOWEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWEN
Provider First Name:
TRINA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1609878917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1449
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GUERNEVILLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95446-1449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-868-5977
Provider Business Mailing Address Fax Number:
707-869-5983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3802 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCCIDENTAL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-874-2444
Provider Business Practice Location Address Fax Number:
707-874-1664
Provider Enumeration Date:
06/01/2005

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: 207Q00000X , with the licence number:  G47095 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1598768962 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: FHC03899G , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00G47095 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZZZ23666Z . This is a "BLUE SHIELD PIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".