Provider Demographics
NPI:1326479296
Name:FOWLER, TINA M (APRN)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:SC
Mailing Address - Zip Code:29379-2838
Mailing Address - Country:US
Mailing Address - Phone:864-441-0802
Mailing Address - Fax:864-441-0801
Practice Address - Street 1:327 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:SC
Practice Address - Zip Code:29379-2838
Practice Address - Country:US
Practice Address - Phone:864-441-0802
Practice Address - Fax:864-441-0801
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN-TP 18609363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8444Medicaid