Basic Information
| Provider Information | |||||||||
| NPI: | 1154426120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOWEN | ||||||||
| FirstName: | LARAINE | ||||||||
| MiddleName: | REIBSON | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 WILLIAM PENN PLAZA | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
| FaxNumber: | 9193131276 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE MEDICAL DRIVE | ||||||||
| Address2: | |||||||||
| City: | BENSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198941740 | ||||||||
| FaxNumber: | 9198942701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 05/24/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04602 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | NCH780E | 01 | NC | MEDICARE | OTHER |