1063740082 NPI number — MISS CHANTELLE E BOWMAN PA-C

Table of content: MISS CHANTELLE E BOWMAN PA-C (NPI 1063740082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063740082 NPI number — MISS CHANTELLE E BOWMAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOWMAN
Provider First Name:
CHANTELLE
Provider Middle Name:
E
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
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:
1063740082
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT HALL
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83203-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-234-2300
Provider Business Mailing Address Fax Number:
208-234-0026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
717 MISSION ROAD
Provider Second Line Business Practice Location Address:
COMMUNITY HEALTH NURSING PROGRAM
Provider Business Practice Location Address City Name:
FORT HALL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-238-5435
Provider Business Practice Location Address Fax Number:
208-238-5440
Provider Enumeration Date:
12/02/2009

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: 363A00000X , with the licence number:  PA-831 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: PA831 . This is a "IDAHO BOARD OF MEDICINE" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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