Provider Demographics
NPI:1912363045
Name:FOWLER, ZACHARY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:FOWLER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-6770
Mailing Address - Country:US
Mailing Address - Phone:862-268-0968
Mailing Address - Fax:
Practice Address - Street 1:601 HEMLOCK DR
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:NJ
Practice Address - Zip Code:07860-6770
Practice Address - Country:US
Practice Address - Phone:862-268-0968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001921002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer