Provider Demographics
NPI:1265145254
Name:BOWIE, CARLISS
Entity type:Individual
Prefix:
First Name:CARLISS
Middle Name:
Last Name:BOWIE
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:PO BOX 267
Mailing Address - Street 2:
Mailing Address - City:BELFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07718-0267
Mailing Address - Country:US
Mailing Address - Phone:347-965-4132
Mailing Address - Fax:
Practice Address - Street 1:11 VAN BRUNT PL
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NJ
Practice Address - Zip Code:07748
Practice Address - Country:US
Practice Address - Phone:347-965-4132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver