Healthcare Provider Details

I. General information

NPI: 1508989468
Provider Name (Legal Business Name): WILEY LELAND FOWLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2007
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 Q STREET
SACRAMENTO CA
95816
US

IV. Provider business mailing address

3400 DATA DR PHYSICIAN SUPPORT SERVICES
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-733-3333
  • Fax:
Mailing address:
  • Phone: 916-379-2948
  • Fax: 916-858-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License NumberA100547
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: