Provider Demographics
NPI:1053786624
Name:BOWERMAN, WAYNE RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:RICHARD
Last Name:BOWERMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 MARINERS WALK WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-5609
Mailing Address - Country:US
Mailing Address - Phone:443-462-7116
Mailing Address - Fax:
Practice Address - Street 1:7 MARINERS WALK WAY
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-5609
Practice Address - Country:US
Practice Address - Phone:443-462-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-08
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC06016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant