Healthcare Provider Details

I. General information

NPI: 1144478801
Provider Name (Legal Business Name): KENNETH D BOWMAN P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2008
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 N WILMA AVE STE A
RIPON CA
95366-9003
US

IV. Provider business mailing address

450 GLASS LN STE C
MODESTO CA
95356-9287
US

V. Phone/Fax

Practice location:
  • Phone: 209-599-4211
  • Fax: 209-599-7348
Mailing address:
  • Phone: 209-342-2300
  • Fax: 209-524-4240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19860
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: