Provider Demographics
NPI:1124367214
Name:FOWLER, CHERYL R (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:R
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:199 S CANDY LN
Practice Address - Street 2:SUITE 1A
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4183
Practice Address - Country:US
Practice Address - Phone:928-649-7969
Practice Address - Fax:928-649-7921
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2016-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ5344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ789677Medicaid
AZ789677Medicaid