Provider Demographics
NPI:1972615920
Name:BOWEN, JEREMY S (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
Last Name:BOWEN
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 1:12860 TROXLER AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-2898
Mailing Address - Country:US
Mailing Address - Phone:618-651-2810
Mailing Address - Fax:618-651-0077
Practice Address - Street 1:12860 TROXLER AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-2898
Practice Address - Country:US
Practice Address - Phone:618-651-2810
Practice Address - Fax:618-651-0077
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCK7203OtherRR GROUP NUMBER
IL207988OtherMEDICARE GROUP NUMBER
NYP019009721OtherBLUE CHOICE
ILP00365761OtherRR MEDICARE NUMBER
NYPA0495OtherPREFERRED CARE
ILK33757Medicare PIN
NYPA0186Medicare ID - Type Unspecified
NYP87565Medicare UPIN