Provider Demographics
NPI:1508440421
Name:FOWLER, BRANDON
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POLE LINE RD W STE 307
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5823
Mailing Address - Country:US
Mailing Address - Phone:208-814-1000
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 307
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5823
Practice Address - Country:US
Practice Address - Phone:208-814-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTL-2379225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist