Provider Demographics
NPI:1992427892
Name:BLAKE, BOWMAN J (APRN)
Entity type:Individual
Prefix:
First Name:BOWMAN
Middle Name:J
Last Name:BLAKE
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3214 N UNIVERSITY AVE # 102
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:861 N 980 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7710
Practice Address - Country:US
Practice Address - Phone:385-262-4135
Practice Address - Fax:801-899-7996
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2022-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10709846-4405207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine