Provider Demographics
NPI:1457654204
Name:FOWLER, SHANNON MARTIN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:MARTIN
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SHANNON
Other - Middle Name:DANIELLE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-5027
Mailing Address - Fax:704-316-5028
Practice Address - Street 1:845 CHURCH ST N STE 203
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4374
Practice Address - Country:US
Practice Address - Phone:704-316-5027
Practice Address - Fax:704-316-5028
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02702363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant