Healthcare Provider Details

I. General information

NPI: 1679162911
Provider Name (Legal Business Name): BRENT J FOWLER CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 JESSE JEWELL PKWY SE STE 360
GAINESVILLE GA
30501-3861
US

IV. Provider business mailing address

3497 ABBEY WAY
GAINESVILLE GA
30507-5045
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-9420
  • Fax:
Mailing address:
  • Phone: 770-530-2732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: