Provider Demographics
NPI:1295962900
Name:BOWMAN, PRENTICE (MD)
Entity type:Individual
Prefix:
First Name:PRENTICE
Middle Name:
Last Name:BOWMAN
Suffix:
Gender:M
Credentials:MD
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 15645
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89114-5645
Mailing Address - Country:US
Mailing Address - Phone:702-877-8600
Mailing Address - Fax:702-242-7944
Practice Address - Street 1:2716 N TENAYA WAY
Practice Address - Street 2:4TH FLOOR
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0424
Practice Address - Country:US
Practice Address - Phone:702-877-8600
Practice Address - Fax:702-242-7944
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070489A207R00000X
NV15771207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1295962900Medicaid
NVV112375Medicare PIN