Basic Information
Provider Information | |||||||||
NPI: | 1497743926 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWERS | ||||||||
FirstName: | ELIZABETH | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BRODERICK | ||||||||
OtherFirstName: | ELIZABETH | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2369 STAPLES MILL RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232302918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042854465 | ||||||||
FaxNumber: | 8042858332 | ||||||||
Practice Location | |||||||||
Address1: | 201 WADSWORTH DR | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | VA | ||||||||
PostalCode: | 232364510 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8042858206 | ||||||||
FaxNumber: | 8043203102 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2005 | ||||||||
LastUpdateDate: | 01/28/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024165193 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 010005167 | 05 | VA |   | MEDICAID |