Basic Information
| Provider Information | |||||||||
| NPI: | 1508036146 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHNNY L. BOWMAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 410 N MAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718522000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708453725 | ||||||||
| FaxNumber: | 8708453322 | ||||||||
| Practice Location | |||||||||
| Address1: | 410 N MAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718522000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708453725 | ||||||||
| FaxNumber: | 8708453322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PERRIN | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8708453725 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 2365 | AR | Y | Managed Care Organizations | Exclusive Provider Organization |
No ID Information.