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NPI Code Detail

MEDICARE: WILEY DOUGLAS FOWLER III PA-C

MEDICARE: WILEY DOUGLAS FOWLER III PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician AssistantPA9106930FL
2363A00000XPhysician AssistantPA9106930FL

General Provider Information

NPI Number : 1780936278
Entity Type Code : Individual
Provider Name (Legal Business Name) : WILEY DOUGLAS FOWLER III PA-C
Provider Business Mailing Address
First Line : PO BOX 746638
Second Line :
City : ATLANTA
State : GA
Zip : 30374-6638
Country : US
Telephone Number : 904-202-2092
Fax Number : 904-376-4075
Provider Business Practice Location Address
First Line : 98 NOCATEE VILLAGE DR
Second Line :
City : PONTE VEDRA
State : FL
Zip : 32081-6152
Country : US
Telephone Number : 904-202-4243
Fax Number : 904-390-7415
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/08/2012
Last Update Date : 12/16/2025

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