Healthcare Provider Details

I. General information

NPI: 1477582880
Provider Name (Legal Business Name): KELLY KOSS BOWLIN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE BOWLIN D.O.

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 WABASHA ST S
SAINT PAUL MN
55107-1805
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-293-8100
  • Fax: 651-293-8106
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number51737
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2005017750- RESIDENT
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number51737
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: