Provider Demographics
NPI:1609527035
Name:BOWE, ANTOINE RASHAD (OWNER)
Entity Type:Individual
Prefix:
First Name:ANTOINE
Middle Name:RASHAD
Last Name:BOWE
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 SPRINGMANN DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-3902
Mailing Address - Country:US
Mailing Address - Phone:571-241-6979
Mailing Address - Fax:571-282-4233
Practice Address - Street 1:10624 SPRINGMANN DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-3902
Practice Address - Country:US
Practice Address - Phone:571-241-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA051485Medicaid