Healthcare Provider Details

I. General information

NPI: 1457553877
Provider Name (Legal Business Name): ALICIA FAYE FOWLER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 LIPSCOMB ST
BONHAM TX
75418-4027
US

IV. Provider business mailing address

505 LIPSCOMB ST
BONHAM TX
75418-4027
US

V. Phone/Fax

Practice location:
  • Phone: 903-640-4809
  • Fax: 903-640-4950
Mailing address:
  • Phone: 903-640-4809
  • Fax: 903-640-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number04822
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: