Provider Demographics
NPI:1336229236
Name:FOWLER, MICHAEL ANTHONY (PAC MPAS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PAC MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SPANISH COURT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707
Mailing Address - Country:US
Mailing Address - Phone:229-438-7100
Mailing Address - Fax:229-438-9382
Practice Address - Street 1:105 SPANISH COURT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707
Practice Address - Country:US
Practice Address - Phone:229-438-7100
Practice Address - Fax:229-438-9382
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1860207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97BBFGTMedicare ID - Type Unspecified