Provider Demographics
NPI:1295731693
Name:BOWAN, NICOLE M (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:BOWAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5500 BROOKTREE RD
Mailing Address - Street 2:STE 201
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-9260
Mailing Address - Country:US
Mailing Address - Phone:724-933-1420
Mailing Address - Fax:724-933-1439
Practice Address - Street 1:5500 BROOKTREE RD
Practice Address - Street 2:STE 201
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-9260
Practice Address - Country:US
Practice Address - Phone:724-933-1420
Practice Address - Fax:724-933-1439
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN890363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3374865Medicaid
3662085Medicare ID - Type Unspecified
Q05710Medicare UPIN