Provider Demographics
NPI:1639602683
Name:FOWLER, NATHAN RYAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RYAN
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 1:7516 CLIFTON GARDENS ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-0101
Mailing Address - Country:US
Mailing Address - Phone:702-279-7278
Mailing Address - Fax:
Practice Address - Street 1:7516 CLIFTON GARDENS ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89166-0101
Practice Address - Country:US
Practice Address - Phone:702-279-7278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002519363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily