Provider Demographics
NPI:1942412812
Name:BOWER, LANE RAE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LANE
Middle Name:RAE
Last Name:BOWER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LANE
Other - Middle Name:RAE
Other - Last Name:BOWER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1994 QUAKER STATE RD
Mailing Address - Street 2:
Mailing Address - City:MONTOURSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17754-8010
Mailing Address - Country:US
Mailing Address - Phone:570-433-4466
Mailing Address - Fax:570-484-2540
Practice Address - Street 1:169 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522-1724
Practice Address - Country:US
Practice Address - Phone:717-738-6355
Practice Address - Fax:717-738-6262
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA-000391-L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS4690Medicare UPIN
PA058322Medicare ID - Type Unspecified