Provider Demographics
NPI:1710740196
Name:BOWMAN, WILLIE (COOK)
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:COOK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 AIRLINE DR APT 912
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5864
Mailing Address - Country:US
Mailing Address - Phone:318-840-3560
Mailing Address - Fax:
Practice Address - Street 1:1525 FULLILOVE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3346
Practice Address - Country:US
Practice Address - Phone:318-222-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA174200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174200000XOther Service ProvidersMeals