Healthcare Provider Details

I. General information

NPI: 1184180614
Provider Name (Legal Business Name): RUBY BOWERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW STE 490
COON RAPIDS MN
55433-2773
US

IV. Provider business mailing address

PO BOX 43
MINNEAPOLIS MN
55440-0043
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-1137
  • Fax:
Mailing address:
  • Phone: 612-622-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number12857
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12857
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: