Healthcare Provider Details

I. General information

NPI: 1881956209
Provider Name (Legal Business Name): JOAN MARIE MASON BOWLIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 02/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST STE 290
EDINA MN
55435-2111
US

IV. Provider business mailing address

3400 W 66TH ST STE 290
EDINA MN
55435-2111
US

V. Phone/Fax

Practice location:
  • Phone: 952-914-1720
  • Fax:
Mailing address:
  • Phone: 952-914-1720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR108944-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: