Provider Demographics
NPI:1144241829
Name:FOWLER, JOHN B
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 SCIENCE DR
Mailing Address - Street 2:COMPLIANCE MAIL CODE-2433
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-1074
Mailing Address - Country:US
Mailing Address - Phone:608-265-4025
Mailing Address - Fax:608-265-8340
Practice Address - Street 1:621 SCIENCE DR
Practice Address - Street 2:COMPLIANCE MAIL CODE-2433
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1074
Practice Address - Country:US
Practice Address - Phone:608-265-4025
Practice Address - Fax:608-265-8340
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI233-039OtherATHLETIC TRAINER