Provider Demographics
NPI:1679577159
Name:FOWLER, JOHN WAKON (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WAKON
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 1:20351 SE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-8145
Mailing Address - Country:US
Mailing Address - Phone:620-672-7422
Mailing Address - Fax:620-508-6476
Practice Address - Street 1:203 WATSON ST STE 200
Practice Address - Street 2:
Practice Address - City:PRATT
Practice Address - State:KS
Practice Address - Zip Code:67124-3092
Practice Address - Country:US
Practice Address - Phone:620-672-7422
Practice Address - Fax:620-508-6476
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0427026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100297620DMedicaid
KSG64061Medicare UPIN
KS055550Medicare ID - Type Unspecified