Provider Demographics
NPI:1073913232
Name:BOWERS, BRIAN
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:BOWERS
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 1:2683 WINCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2148
Mailing Address - Country:US
Mailing Address - Phone:215-813-6334
Mailing Address - Fax:
Practice Address - Street 1:2683 WINCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2148
Practice Address - Country:US
Practice Address - Phone:215-813-6334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered