Provider Demographics
NPI:1053827196
Name:FOWOWE, MICHAEL OLUWASOGO (PA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:OLUWASOGO
Last Name:FOWOWE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2976 SIWANOY DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-3435
Mailing Address - Country:US
Mailing Address - Phone:443-414-3587
Mailing Address - Fax:410-296-1687
Practice Address - Street 1:1045 TAYLOR AVE STE 104
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286-8315
Practice Address - Country:US
Practice Address - Phone:410-296-0180
Practice Address - Fax:410-296-1587
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0006689363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical