Provider Demographics
NPI:1952539975
Name:BOWEN, MICHELLE M (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
Last Name:BOWEN
Suffix:
Gender:F
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:PO BOX 198
Mailing Address - Street 2:
Mailing Address - City:OQUAWKA
Mailing Address - State:IL
Mailing Address - Zip Code:61469-0198
Mailing Address - Country:US
Mailing Address - Phone:309-867-2202
Mailing Address - Fax:309-867-2789
Practice Address - Street 1:1400 E CARROLL ST
Practice Address - Street 2:SUITE B
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-1801
Practice Address - Country:US
Practice Address - Phone:309-833-2500
Practice Address - Fax:309-833-1760
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004266363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN815150HHHHMedicare PIN
INM400017854Medicare PIN