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General NPI Number Information
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NPI Number | 1093519837
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Entity Type | Individual
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Provider Name | RAPHAEL B FOWLER AGPCNP-C
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Gender | Male
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Dates
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Enumeration Date | 04/02/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 4958 MEMORIAL DR
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-4148
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Country | US
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Telephone | 678-542-9756
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Fax |
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Provider Business Mailing Address
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Address Line | 3387 PEACHTREE CORNERS CIR APT I
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City | PEACHTREE CORNERS
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State | GA
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Zip | 30092-4351
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Country | US
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Telephone | 678-542-9756
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | RN276645
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License Number State | GA
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