Provider Demographics
NPI:1912060310
Name:FOWLER, MIRANDA C (MD)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:C
Last Name:FOWLER
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 1:2909 SE WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66605-2189
Mailing Address - Country:US
Mailing Address - Phone:785-267-0744
Mailing Address - Fax:
Practice Address - Street 1:2909 SE WALNUT DR
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66605-2189
Practice Address - Country:US
Practice Address - Phone:785-267-0744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0432985207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002352OtherMEDICARE PTAN
KS201086730BMedicaid