Basic Information
| Provider Information | |||||||||
| NPI: | 1366529315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | MARIYA | ||||||||
| MiddleName: | V | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2910 CENTRE POINTE DRIVE | ||||||||
| Address2: | 35 121A CHILDRENS HEALTH CARE | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518552327 | ||||||||
| FaxNumber: | 6518552310 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 NORTH SMITH AVENUE | ||||||||
| Address2: | CHILDRENS HOSPITALS & CLINICS OF MN EMERG PHYS STPL | ||||||||
| City: | ST PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512206914 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R1706714 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | R1706714 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP2300X | R1706714 | MN | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.