Healthcare Provider Details

I. General information

NPI: 1033756887
Provider Name (Legal Business Name): GRADY FOWLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

IV. Provider business mailing address

2100 LOUISIANA BLVD NE STE 410
ALBUQUERQUE NM
87110-5412
US

V. Phone/Fax

Practice location:
  • Phone: 505-724-4300
  • Fax: 505-338-0034
Mailing address:
  • Phone: 505-724-4300
  • Fax: 505-338-0034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: