Provider Demographics
NPI:1184180614
Name:BOWERS, RUBY
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:
Last Name:BOWERS
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 1:11850 BLACKFOOT ST NW
Mailing Address - Street 2:STE 490
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2773
Mailing Address - Country:US
Mailing Address - Phone:218-234-9043
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 490
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2773
Practice Address - Country:US
Practice Address - Phone:763-427-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12857363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant