Provider Demographics
NPI:1720627888
Name:BOWERS, KEITH (CRNA, DNP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BOWERS
Suffix:
Gender:M
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 BRIARCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2658
Mailing Address - Country:US
Mailing Address - Phone:815-210-7520
Mailing Address - Fax:
Practice Address - Street 1:611 W PARK ST
Practice Address - Street 2:FAPC
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801
Practice Address - Country:US
Practice Address - Phone:217-902-5292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.408998163W00000X
IL209020767367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse