Provider Demographics
NPI:1417707761
Name:BOWEN, TARA ROQUELLE
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:ROQUELLE
Last Name:BOWEN
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 1:2098 RIDGEWAY RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-6304
Mailing Address - Country:US
Mailing Address - Phone:901-722-6486
Mailing Address - Fax:
Practice Address - Street 1:2098 RIDGEWAY RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-6304
Practice Address - Country:US
Practice Address - Phone:901-722-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory