Provider Demographics
NPI:1043228729
Name:BOWMAN, TRACY (PA)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12156
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-2156
Mailing Address - Country:US
Mailing Address - Phone:757-867-6593
Mailing Address - Fax:757-867-6588
Practice Address - Street 1:1705 TARBORO ST SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-3428
Practice Address - Country:US
Practice Address - Phone:252-399-8928
Practice Address - Fax:252-399-7477
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06396363AM0700X
CT001588363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1043228729Medicaid
CT970002184Medicare PIN