Provider Demographics
NPI:1417493263
Name:BOWMAN, CONN
Entity Type:Individual
Prefix:
First Name:CONN
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 CAMPUS DR
Mailing Address - Street 2:MCGILL 238
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59812-0003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 CAMPUS DR
Practice Address - Street 2:MCGILL 238
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0003
Practice Address - Country:US
Practice Address - Phone:406-243-2703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program