1326070665 NPI number — BRADLEY P BOWMAN M.D.

Table of content: BRADLEY P BOWMAN M.D. (NPI 1326070665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326070665 NPI number — BRADLEY P BOWMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWMAN
Provider First Name:
BRADLEY
Provider Middle Name:
P
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1326070665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 SE BISHOP BLVD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PULLMAN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99163-5537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-332-2517
Provider Business Mailing Address Fax Number:
509-334-9247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3355 FOOTHILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOSCOW
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83843-8765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-332-2517
Provider Business Practice Location Address Fax Number:
509-334-9247
Provider Enumeration Date:
07/07/2006

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:  MD00045278 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807307400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8431546 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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