Provider Demographics
NPI:1558604181
Name:BOWERS, MELISSA J (MSED, ATC, OTC)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:J
Last Name:BOWERS
Suffix:
Gender:F
Credentials:MSED, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 WOODDALE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1947
Mailing Address - Country:US
Mailing Address - Phone:651-968-5360
Mailing Address - Fax:
Practice Address - Street 1:1860 WOODDALE DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1947
Practice Address - Country:US
Practice Address - Phone:651-968-5360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-02
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20100288762255A2300X
CO10882255A2300X
COSA.0001691246ZS0410X
MN25002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist