Basic Information
| Provider Information | |||||||||
| NPI: | 1356579478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | RITA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DERR | ||||||||
| OtherFirstName: | RITA | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1439 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218895 | ||||||||
| FaxNumber: | 4027216663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1439 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | FREMONT | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680252433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027218895 | ||||||||
| FaxNumber: | 4027216663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 07/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1448 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.