Provider Demographics
NPI:1124367214
Name:FOWLER, DRELAN CHE-STEWART (PA-C)
Entity type:Individual
Prefix:
First Name:DRELAN
Middle Name:CHE-STEWART
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:CHERYL
Other - Middle Name:R
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:919 12TH PL STE 12
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-1433
Mailing Address - Country:US
Mailing Address - Phone:928-227-1954
Mailing Address - Fax:480-591-8225
Practice Address - Street 1:919 12TH PL STE 12
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-1433
Practice Address - Country:US
Practice Address - Phone:928-227-1954
Practice Address - Fax:480-591-8225
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ789677Medicaid
AZ789677Medicaid