Basic Information
| Provider Information | |||||||||
| NPI: | 1003847286 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWYER | ||||||||
| FirstName: | TONI | ||||||||
| MiddleName: | HICKS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 98 WILLOW LN | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293071357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645855552 | ||||||||
| FaxNumber: | 8645970179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-00456 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 0010-00456 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 1068 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA1068 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0470PA | 05 | SC | MEDICAID | SCM2214292 | 01 | SC | MEDICARE PTAN | OTHER | NNK275A | 01 | NC | MEDICARE PTAN | OTHER | 1003847286 | 05 | NC | MEDICAID |