Provider Demographics
NPI:1811079528
Name:FOWLER, JOSEPH L JR (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:L
Last Name:FOWLER
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 E BARNETT RD STE H
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:500 SW RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5543
Practice Address - Country:US
Practice Address - Phone:541-472-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63750367500000X
OR201408269CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00656985OtherRR MEDICARE
IA1811079528Medicaid
1811079528OtherWELLMARK BLUE CROSS BLUE SHIELD
1811079528OtherWELLMARK BLUE CROSS BLUE SHIELD