Provider Demographics
NPI:1134507783
Name:BOWEN, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:BOWEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:651-232-7701
Mailing Address - Fax:
Practice Address - Street 1:14688 EVERTON AVE N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-6071
Practice Address - Country:US
Practice Address - Phone:651-326-7701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN60683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program