Basic Information
Provider Information | |||||||||
NPI: | 1659780351 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWLES | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | ROSEMARY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WHEELER | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | ROSEMARY | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1650 28TH ST UNIT 1232 | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803011013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036848252 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1650 28TH ST UNIT 1232 | ||||||||
Address2: |   | ||||||||
City: | BOULDER | ||||||||
State: | CO | ||||||||
PostalCode: | 803011013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5036848252 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2014 | ||||||||
LastUpdateDate: | 12/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP15586 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APN.0991104-NP | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.