Provider Demographics
NPI:1942236948
Name:BOWLES, MATTHEW B (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:B
Last Name:BOWLES
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3430
Mailing Address - Fax:540-776-2051
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3430
Practice Address - Fax:540-776-2051
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1942236948Medicaid
VA020775L84Medicare PIN
VAP00272044Medicare PIN
VA00W626S11Medicare PIN
VAP00741254Medicare PIN
VAQ28322Medicare UPIN