Provider Demographics
NPI:1255432860
Name:BOWDEN, SHYANNE D
Entity type:Individual
Prefix:
First Name:SHYANNE
Middle Name:D
Last Name:BOWDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 CHAPARRAL LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-2005
Mailing Address - Country:US
Mailing Address - Phone:817-683-6206
Mailing Address - Fax:
Practice Address - Street 1:1310 PALUXY RD
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5655
Practice Address - Country:US
Practice Address - Phone:817-573-2273
Practice Address - Fax:817-579-3926
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00141489367500000X
TX662113367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193355803Medicaid
WA9644410Medicaid
WA196542OtherL&I