Healthcare Provider Details

I. General information

NPI: 1033799564
Provider Name (Legal Business Name): DESTINEE BRIANA FOWLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DESTINEE BRIANA HAGAMAN

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 TINY TOWN RD STE A1-A2
CLARKSVILLE TN
37042-7873
US

IV. Provider business mailing address

745 TRACY LN UNIT 113
CLARKSVILLE TN
37040-0064
US

V. Phone/Fax

Practice location:
  • Phone: 615-553-5000
  • Fax: 615-758-3875
Mailing address:
  • Phone: 302-399-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4534
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: