Provider Demographics
NPI:1033215462
Name:BIBB DOWLER, MYRA (PA)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:BIBB DOWLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:
Other - Last Name:BIBB-DEVOLLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:937-522-8068
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR STE 130
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4094
Practice Address - Country:US
Practice Address - Phone:937-531-0195
Practice Address - Fax:937-531-0196
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001134363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090079Medicaid
OH50001134OtherSTATE LICENSE
OHH065170Medicare PIN
OH0090079Medicaid