Provider Demographics
NPI:1063740082
Name:BOWMAN, CHANTELLE E (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CHANTELLE
Middle Name:E
Last Name:BOWMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:FORT HALL
Mailing Address - State:ID
Mailing Address - Zip Code:83203-0306
Mailing Address - Country:US
Mailing Address - Phone:208-234-2300
Mailing Address - Fax:208-234-0026
Practice Address - Street 1:717 MISSION ROAD
Practice Address - Street 2:COMMUNITY HEALTH NURSING PROGRAM
Practice Address - City:FORT HALL
Practice Address - State:ID
Practice Address - Zip Code:83203
Practice Address - Country:US
Practice Address - Phone:208-238-5435
Practice Address - Fax:208-238-5440
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-831363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPA831OtherIDAHO BOARD OF MEDICINE