Provider Demographics
NPI:1003466095
Name:BOWERSOX, DYLAN LEE
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:LEE
Last Name:BOWERSOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MIFFLINBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17844-8250
Mailing Address - Country:US
Mailing Address - Phone:570-428-5047
Mailing Address - Fax:
Practice Address - Street 1:2380 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:MIFFLINBURG
Practice Address - State:PA
Practice Address - Zip Code:17844-8250
Practice Address - Country:US
Practice Address - Phone:570-428-5047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0002322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer