Provider Demographics
NPI:1255699377
Name:FOWLKES, EMILIE AISLINN WEED (MD)
Entity type:Individual
Prefix:
First Name:EMILIE
Middle Name:AISLINN WEED
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4096
Mailing Address - Country:US
Mailing Address - Phone:406-329-5635
Mailing Address - Fax:406-329-5639
Practice Address - Street 1:500 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4096
Practice Address - Country:US
Practice Address - Phone:406-329-5635
Practice Address - Fax:406-329-5639
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-9489207P00000X
IAMD-42440207P00000X
390200000X
MT63900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program