Provider Demographics
NPI:1740926047
Name:BOWERMAN, ELIZABETH GRACE
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:GRACE
Last Name:BOWERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:GRACE
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:501 CLYMER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3010
Mailing Address - Country:US
Mailing Address - Phone:301-503-1150
Mailing Address - Fax:
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4395
Practice Address - Country:US
Practice Address - Phone:301-503-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023780363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics