Provider Demographics
NPI:1215224886
Name:FOWLER, AMANDA HORNE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:HORNE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:HORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:DEPT. OF MEDICINE
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5601
Mailing Address - Fax:601-984-6665
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPT. OF MEDICINE
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-5601
Practice Address - Fax:601-984-6665
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS22571207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00886302Medicaid
MS00886302Medicaid