Provider Demographics
NPI:1114380961
Name:BOWMAN, ANTONDRA MICHOLE (DPT)
Entity Type:Individual
Prefix:
First Name:ANTONDRA
Middle Name:MICHOLE
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3911
Mailing Address - Country:US
Mailing Address - Phone:912-682-7867
Mailing Address - Fax:
Practice Address - Street 1:7111 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2965
Practice Address - Country:US
Practice Address - Phone:559-500-1042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist