Provider Demographics
NPI:1003847286
Name:BOWYER, TONI HICKS (PA-C)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:HICKS
Last Name:BOWYER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT. 453 PO 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:98 WILLOW LN
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1357
Practice Address - Country:US
Practice Address - Phone:864-585-5552
Practice Address - Fax:864-597-0179
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA1068363A00000X
NC0010-00456363A00000X, 363AM0700X
SC1068363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNNK275AOtherMEDICARE PTAN
SCSCM2214292OtherMEDICARE PTAN
SC0470PAMedicaid
NC1003847286Medicaid
SC0470PAMedicaid