{
"Npi": {
"NPI": "1073532404",
"EntityType": "Individual",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": "Y",
"IsOrgSubpart": null,
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": null,
"LastName": "FOWLER",
"FirstName": "TIMOTHY",
"MiddleName": "DALE",
"NamePrefix": "MR.",
"NameSuffix": "JR.",
"Credential": "P.A.",
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "209 N CUTHBERT ST",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "COLQUITT",
"MailingAddressStateName": "GA",
"MailingAddressPostalCode": "39837-3518",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "229-758-4864",
"MailingAddressFaxNumber": "229-758-8473",
"FirstLinePracticeLocationAddress": "601 E ROLLINS ST",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "ORLANDO",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32803-1248",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "407-543-5732",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "07/18/2006",
"LastUpdateDate": "06/02/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": "M",
"Gender": "Male",
"AuthorizedOfficialLastName": null,
"AuthorizedOfficialFirstName": null,
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": null,
"AuthorizedOfficialNamePrefix": null,
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": null,
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "363A00000X",
"TaxonomyName": "Physician Assistant",
"LicenseNumber": "003482",
"LicenseNumberStateCode": "GA",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}