Provider Demographics
NPI:1841765203
Name:FOWLER, CHARLES (APRN-BC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 ORANGE ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-2229
Mailing Address - Country:US
Mailing Address - Phone:740-622-6411
Mailing Address - Fax:
Practice Address - Street 1:1460 ORANGE ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-2229
Practice Address - Country:US
Practice Address - Phone:740-622-6411
Practice Address - Fax:740-295-5921
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTNUR-APRN-LIC-145055363LF0000X
OHAPRN.CNP.023759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0446622Medicaid