Basic Information
Provider Information | |||||||||
NPI: | 1457318438 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWEN | ||||||||
FirstName: | KENDRA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PAC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1441 W BROADWAY | ||||||||
Address2: |   | ||||||||
City: | CENTRALIA | ||||||||
State: | IL | ||||||||
PostalCode: | 628015613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185329050 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1441 W BROADWAY | ||||||||
Address2: |   | ||||||||
City: | CENTRALIA | ||||||||
State: | IL | ||||||||
PostalCode: | 628015613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6185329050 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2006 | ||||||||
LastUpdateDate: | 11/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 010234 | NY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 085003158 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | P00469189 | 01 | IL | RR MEDICARE PTAN | OTHER | 208959 | 01 | IL | MED GRP # | OTHER | CE9335 | 01 | IL | RR GROUP # | OTHER | 207988 | 01 | IL | MED GROUP # | OTHER |