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General NPI Number Information
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NPI Number | 1265849343
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Entity Type | Individual
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Provider Name | GARY ANTHONY RUDOLPH BOWEN PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/21/2014
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Last Update Date | 07/21/2014
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Provider Practice Location Address
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Address Line | 1014 SYCAMORE DR SUITE B
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City | DECATUR
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State | GA
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Zip | 30030-1644
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Country | US
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Telephone | 404-480-4229
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Fax |
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Provider Business Mailing Address
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Address Line | 825 COMMON OAK PL
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City | LAWRENCEVILLE
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State | GA
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Zip | 30045-8256
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Country | US
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Telephone | 210-781-3997
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 7262
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License Number State | GA
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