Basic Information
Provider Information | |||||||||
NPI: | 1841632486 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOWEN | ||||||||
FirstName: | LINDSEY | ||||||||
MiddleName: | HOPKINS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-AA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOPKINS | ||||||||
OtherFirstName: | LINDSEY | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-AA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9200 W WISCONSIN AVE | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532263522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148058700 | ||||||||
FaxNumber: | 4142591522 | ||||||||
Practice Location | |||||||||
Address1: | 1199 PRINCE AVE | ||||||||
Address2: |   | ||||||||
City: | ATHENS | ||||||||
State: | GA | ||||||||
PostalCode: | 306062797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7063543666 | ||||||||
FaxNumber: | 7065435744 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2013 | ||||||||
LastUpdateDate: | 04/08/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/08/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 006987 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   | 367H00000X | 110 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 003140116B | 01 | GA | MEDICAID | OTHER | 003140116A | 05 | GA |   | MEDICAID | 1841632486 | 05 | WI |   | MEDICAID |