Healthcare Provider Details

I. General information

NPI: 1730287111
Provider Name (Legal Business Name): WYATT CHARLES FOWLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 QUEENS RD STE 430
CHARLOTTE NC
28204-3215
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-6300
  • Fax: 980-302-6305
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number38940
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number38940
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: