Provider Demographics
NPI:1255316261
Name:POWERS-BOWIER, JACQUELINE (PA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:POWERS-BOWIER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:951-360-5250
Mailing Address - Fax:951-360-9069
Practice Address - Street 1:6250 CLAY ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-6005
Practice Address - Country:US
Practice Address - Phone:951-360-5250
Practice Address - Fax:951-360-9069
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11483207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ14058ZOtherGROUP SITE LOCATION
ZZZ14058ZOtherGROUP SITE LOCATION
S64207Medicare UPIN