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General NPI Number Information
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NPI Number | 1841743747
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Entity Type | Individual
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Provider Name | WON GIN JACKSON BOWMAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/27/2016
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Last Update Date | 10/26/2020
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Provider Practice Location Address
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Address Line | 50 MILLER ST STE C
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City | WINSTON SALEM
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State | NC
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Zip | 27104-4206
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Country | US
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Telephone | 336-310-5535
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Fax | 336-310-1183
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Provider Business Mailing Address
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Address Line | PO BOX 601843
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City | CHARLOTTE
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State | NC
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Zip | 28260-1843
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Country | US
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Telephone |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0110005475
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-09114
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License Number State | NC
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