Basic Information
| Provider Information | |||||||||
| NPI: | 1649538505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLE | ||||||||
| FirstName: | EVAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 NE 97TH ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731146302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058422061 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2012 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 6290 | OK | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.