Provider Demographics
NPI:1730287111
Name:FOWLER, WYATT CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:CHARLES
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 QUEENS RD STE 430
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3215
Practice Address - Country:US
Practice Address - Phone:980-302-6300
Practice Address - Fax:980-302-6305
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC389402086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8910272Medicaid
NC10272OtherBLUE CROSS AND BLUE SHIEL
SCN38940Medicaid
NC2234715Medicare ID - Type Unspecified
NCG45439Medicare UPIN