Individual
JETA LAURIE BOWMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
AGNP
Contact information
Practice address
520 DOUGLAS BLVD, TYLER, TX 75702
(903) 606-1721
Mailing address
PO BOX 846098, DALLAS, TX 75284-6098
(903) 324-6400
Taxonomy
Speciality
Code
Description
License number
State
363LA2200X
Adult Health Nurse Practitioner
Primary
AP130960
TX
363LG0600X
Gerontology Nurse Practitioner
AP130960
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
381618302
—
TX
01
—
787876
MEDICARE
TX
01
—
P02223408
MEDICARE RAIL ROAD
TX
Enumeration date
05/20/2016
Last updated
07/01/2019
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