Provider Demographics
NPI:1457318438
Name:BOWEN, KENDRA D (PAC)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:D
Last Name:BOWEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 W BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801-5613
Mailing Address - Country:US
Mailing Address - Phone:618-532-9050
Mailing Address - Fax:
Practice Address - Street 1:1441 W BROADWAY
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801-5613
Practice Address - Country:US
Practice Address - Phone:618-532-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010234363AS0400X
IL085003158363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00469189OtherRR MEDICARE PTAN
IL208959OtherMED GRP #
ILCE9335OtherRR GROUP #
IL207988OtherMED GROUP #
IL207988OtherMED GROUP #
ILCE9335OtherRR GROUP #
ILR00607Medicare PIN