Provider Demographics
NPI:1073580056
Name:FOWLER, DEBORAH A (P,A-C)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:A
Last Name:FOWLER
Suffix:
Gender:F
Credentials:P,A-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16216 PINE LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-629-8703
Mailing Address - Fax:
Practice Address - Street 1:102 N ADELAIDE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-2670
Practice Address - Country:US
Practice Address - Phone:810-629-2245
Practice Address - Fax:810-629-6535
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMF0924630OtherMEDICARE RR ID
MIMF0924630OtherMEDICARE RR ID
MIN90460001Medicare ID - Type UnspecifiedMEDICARE ID