Provider Demographics
NPI:1891782900
Name:FOWLER, MANDI C (PA-C)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:C
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:L
Other - Last Name:CZYKYSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 PROFESSIONAL PL
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3874
Mailing Address - Country:US
Mailing Address - Phone:770-834-3351
Mailing Address - Fax:770-830-1518
Practice Address - Street 1:677 CHURCH ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1101
Practice Address - Country:US
Practice Address - Phone:470-793-6120
Practice Address - Fax:770-999-2647
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3873363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA875872035BMedicaid
GA875872035FMedicaid
GA647119263AMedicaid
GA875872035CMedicaid
GA875872035EMedicaid
GA875872035DMedicaid
GA202I976269Medicare PIN
GA875872035CMedicaid