Provider Demographics
NPI:1790916443
Name:BOWEN, VIRGINIA K (PT)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:K
Last Name:BOWEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 MILLSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1242
Mailing Address - Country:US
Mailing Address - Phone:414-421-8014
Mailing Address - Fax:
Practice Address - Street 1:402 FIRST STREET
Practice Address - Street 2:
Practice Address - City:RANDOM LAKE
Practice Address - State:WI
Practice Address - Zip Code:53075
Practice Address - Country:US
Practice Address - Phone:920-994-9700
Practice Address - Fax:920-994-4606
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3453024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist