Provider Demographics
NPI:1164772190
Name:BOWDOIN, SHAWN RUSSELL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:RUSSELL
Last Name:BOWDOIN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 482
Mailing Address - Street 2:BOX 4
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96362-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PSC 482
Practice Address - Street 2:BOX 4
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96362-9998
Practice Address - Country:US
Practice Address - Phone:315-643-7490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA87780OtherNATIONAL BOARD OF CERTIFICATION REGISTERED NURSE ANESTHETIST