Provider Demographics
NPI:1669511176
Name:BOWEN, MARSHALL JOHNSON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MARSHALL
Middle Name:JOHNSON
Last Name:BOWEN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 HALLMARK RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-2616
Mailing Address - Country:US
Mailing Address - Phone:910-864-2841
Mailing Address - Fax:
Practice Address - Street 1:607 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2603
Practice Address - Country:US
Practice Address - Phone:910-592-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC015989367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050555Medicaid
NC8050555Medicaid