Basic Information
Provider Information | |||||||||
NPI: | 1447560321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWERMAN | ||||||||
FirstName: | GEMMA | ||||||||
MiddleName: | V | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 188 | ||||||||
Address2: |   | ||||||||
City: | MARANA | ||||||||
State: | AZ | ||||||||
PostalCode: | 856530188 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206824111 | ||||||||
FaxNumber: | 5206824570 | ||||||||
Practice Location | |||||||||
Address1: | 2355 N WYATT DR | ||||||||
Address2: | SUITE 101 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857122120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5206164948 | ||||||||
FaxNumber: | 5206164958 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2010 | ||||||||
LastUpdateDate: | 07/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 132854 | AZ | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 3756 | AZ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 568360 | 05 | AZ |   | MEDICAID |