Basic Information
| Provider Information | |||||||||
| NPI: | 1619047362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOWMAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | KANAB | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847413260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356444100 | ||||||||
| FaxNumber: | 4356443366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5349812 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 107023013101 | 01 | UT | SELECT HEALTH | OTHER | D5247 | 05 | UT | MEDICAID | 53498121200001 | 01 | UT | BCBS | OTHER |