=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891518429
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANDY BOWER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 727 FRONT AVE APT 1408
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55103-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-497-9315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 727 FRONT AVE APT 1408
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55103-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-497-9315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | NRG24678
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------