Individual
KENDRA D BOWEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
1441 W BROADWAY, CENTRALIA, IL 62801-5613
(618) 532-9050
Mailing address
1441 W BROADWAY, CENTRALIA, IL 62801-5613
(618) 532-9050
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085003158
IL
363AS0400X
Surgical Physician Assistant
010234
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
207988
MED GROUP #
IL
01
—
208959
MED GRP #
IL
01
—
CE9335
RR GROUP #
IL
01
—
P00469189
RR MEDICARE PTAN
IL
Enumeration date
04/26/2006
Last updated
11/12/2020
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