Provider Demographics
NPI:1598954208
Name:FOWLER, SHELLY A (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:A
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 313
Mailing Address - Street 2:
Mailing Address - City:LEEDS
Mailing Address - State:MA
Mailing Address - Zip Code:01053-0313
Mailing Address - Country:US
Mailing Address - Phone:413-727-3882
Mailing Address - Fax:
Practice Address - Street 1:38 MULBERRY ST STE 204
Practice Address - Street 2:
Practice Address - City:LEEDS
Practice Address - State:MA
Practice Address - Zip Code:01053-5339
Practice Address - Country:US
Practice Address - Phone:413-727-3882
Practice Address - Fax:413-727-8691
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002021363A00000X
MAPA1051363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003020211Medicaid
CT970002752 (C00814)Medicare PIN