Basic Information
| Provider Information | |||||||||
| NPI: | 1811952500 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 612 SHENANDOAH RD W | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366083353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2513443180 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6801 AIRPORT BLVD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366083709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516313270 | ||||||||
| FaxNumber: | 2516313273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1-062685 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.