Provider Demographics
NPI:1912538976
Name:MAXIMO- BOWMAN, LATRESHIA SHANAE (BARBER)
Entity Type:Individual
Prefix:MRS
First Name:LATRESHIA
Middle Name:SHANAE
Last Name:MAXIMO- BOWMAN
Suffix:
Gender:F
Credentials:BARBER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5441 BALTIMORE NATIONAL PIKE STE 2A
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-2102
Mailing Address - Country:US
Mailing Address - Phone:553-527-3742
Mailing Address - Fax:
Practice Address - Street 1:5441 BALTIMORE NATIONAL PIKE STE 2A
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-2102
Practice Address - Country:US
Practice Address - Phone:553-527-3742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1076091744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty