Provider Demographics
NPI:1841743747
Name:BOWMAN, WON GIN JACKSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:WON GIN
Middle Name:JACKSON
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 MILLER ST STE C
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-4206
Practice Address - Country:US
Practice Address - Phone:336-310-5535
Practice Address - Fax:336-310-1183
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005475363AM0700X
NC0010-09114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110005475OtherSTATE LICENSE
VAVVL892AMedicare UPIN