Healthcare Provider Details

I. General information

NPI: 1942003132
Provider Name (Legal Business Name): GAGE FOWLER AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 ROGERS AVE
FORT SMITH AR
72903-4100
US

IV. Provider business mailing address

PO BOX 776084
CHICAGO IL
60677-6084
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-6000
  • Fax:
Mailing address:
  • Phone: 479-314-6000
  • Fax: 479-314-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number233166
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR109320
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: