Provider Demographics
NPI:1265849343
Name:BOWEN, GARY ANTHONY RUDOLPH (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ANTHONY RUDOLPH
Last Name:BOWEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 COMMON OAK PL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-8256
Mailing Address - Country:US
Mailing Address - Phone:210-781-3997
Mailing Address - Fax:
Practice Address - Street 1:1014 SYCAMORE DR
Practice Address - Street 2:SUITE B
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1644
Practice Address - Country:US
Practice Address - Phone:404-480-4229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7262363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant