Healthcare Provider Details

I. General information

NPI: 1588372114
Provider Name (Legal Business Name): MR. SCOTT EDWARD BOWERMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1320 MAPLEWOOD AVE
RONCEVERTE WV
24970-8016
US

IV. Provider business mailing address

3765 SAINT JAMES RD
GREENEVILLE TN
37743-1743
US

V. Phone/Fax

Practice location:
  • Phone: 304-793-2220
  • Fax: 304-793-2277
Mailing address:
  • Phone: 423-470-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: