Provider Demographics
NPI:1801201173
Name:FOWLER, TRACY M (APRN/PNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:APRN/PNP
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 1215
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-1215
Mailing Address - Country:US
Mailing Address - Phone:620-629-6638
Mailing Address - Fax:620-629-6684
Practice Address - Street 1:555 W 15TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2467
Practice Address - Country:US
Practice Address - Phone:620-624-0702
Practice Address - Fax:620-624-5078
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS5376397363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics