Provider Demographics
NPI:1740517010
Name:BOWMAN, STACI (MED)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04574-3627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 W WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:ME
Practice Address - Zip Code:04574-3627
Practice Address - Country:US
Practice Address - Phone:207-845-6070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-07
Last Update Date:2009-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433357000Medicaid