Provider Demographics
NPI:1649866377
Name:BOWEN, KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BOWEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12547 OCEAN GTWY
Mailing Address - Street 2:
Mailing Address - City:OCEAN CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21842-9689
Mailing Address - Country:US
Mailing Address - Phone:410-213-0119
Mailing Address - Fax:
Practice Address - Street 1:12547 OCEAN GTWY
Practice Address - Street 2:
Practice Address - City:OCEAN CITY
Practice Address - State:MD
Practice Address - Zip Code:21842-9689
Practice Address - Country:US
Practice Address - Phone:410-213-0119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007762363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty