Provider Demographics
NPI:1083291983
Name:BOWLIN, ETHAN MANNING (DO)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:MANNING
Last Name:BOWLIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32100 GRAND RIVER AVE UNIT 107
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4176
Mailing Address - Country:US
Mailing Address - Phone:970-218-9117
Mailing Address - Fax:
Practice Address - Street 1:5333 MCAULEY DRIVE
Practice Address - Street 2:SUITE 4001
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8633
Practice Address - Country:US
Practice Address - Phone:734-712-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program