Provider Demographics
NPI:1477628006
Name:FOWLER, PATRICK T (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:T
Last Name:FOWLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 EDITH AVE
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-3043
Mailing Address - Country:US
Mailing Address - Phone:530-241-3316
Mailing Address - Fax:530-241-6319
Practice Address - Street 1:2626 EDITH AVE STE C
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-3056
Practice Address - Country:US
Practice Address - Phone:530-241-3316
Practice Address - Fax:530-241-6319
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78482208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA340016697OtherRAILROAD MEDICARE
CAG78482OtherMEDICAL LICENSE
CA00G784820Medicaid
CA05D0617976OtherCLIA ID
CAZZZ78528ZMedicaid
CACP5241OtherRAILROAD MEDICARE GROUP