Provider Demographics
NPI:1275549479
Name:FOWLER, STACY (DPM)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-7116
Mailing Address - Country:US
Mailing Address - Phone:336-213-3910
Mailing Address - Fax:
Practice Address - Street 1:1613 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-7116
Practice Address - Country:US
Practice Address - Phone:336-213-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC481213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89081AJMedicaid
NC081AJOtherBLUE CROSS
NC11453384OtherFIRST HEALTH
NC89081AJMedicaid
NC2430092Medicare ID - Type Unspecified