Healthcare Provider Details

I. General information

NPI: 1639546344
Provider Name (Legal Business Name): NICHOLAS JON FOWLER AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 NW GARDEN VALLEY BLVD AUDIOLOGY DEPT.
ROSEBURG OR
97471-6523
US

IV. Provider business mailing address

913 NW GARDEN VALLEY BLVD AUDIOLOGY DEPT.
ROSEBURG OR
97471-6523
US

V. Phone/Fax

Practice location:
  • Phone: 541-290-8441
  • Fax:
Mailing address:
  • Phone: 541-290-8441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number030837
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: