Healthcare Provider Details

I. General information

NPI: 1821621269
Provider Name (Legal Business Name): RITA BOLOUS MCCOWAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. RITA BOLOUS

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

7532 ALTURA PL
OAKLAND CA
94605-3108
US

V. Phone/Fax

Practice location:
  • Phone: 510-428-3000
  • Fax:
Mailing address:
  • Phone: 650-773-5396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95009963
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: