Basic Information
| Provider Information | |||||||||
| NPI: | 1447268271 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA/AA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2564 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DRIVE | ||||||||
| Address2: | SUITE 410 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 002468 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | 100001578B | 05 | GA | MEDICAID | 100001578D | 05 | GA | MEDICAID | 970026294 | 01 | GA | RAILROAD MEDICARE | OTHER | 100001578C | 05 | GA | MEDICAID | 336920 | 01 | GA | WELLCARE | OTHER | 100001578A | 05 | GA | MEDICAID |