Healthcare Provider Details

I. General information

NPI: 1598750374
Provider Name (Legal Business Name): GAIL MARIE FOWLER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SIESTA DR STE 201
SARASOTA FL
34239-5200
US

IV. Provider business mailing address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

V. Phone/Fax

Practice location:
  • Phone: 813-321-1786
  • Fax: 813-321-1787
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106446
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000571
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: