Healthcare Provider Details

I. General information

NPI: 1073580056
Provider Name (Legal Business Name): DEBORAH A FOWLER P,A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N ADELAIDE ST
FENTON MI
48430-2670
US

IV. Provider business mailing address

16216 PINE LAKE FOREST DR
FENTON MI
48430
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-2245
  • Fax: 810-629-6535
Mailing address:
  • Phone: 810-629-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001505
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: