Provider Demographics
NPI:1649344276
Name:FOWLER, JAMES MARK (PT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MARK
Last Name:FOWLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1730
Mailing Address - Street 2:
Mailing Address - City:MORIARTY
Mailing Address - State:NM
Mailing Address - Zip Code:87035-1730
Mailing Address - Country:US
Mailing Address - Phone:505-832-4011
Mailing Address - Fax:
Practice Address - Street 1:2005 W US ROUTE 66
Practice Address - Street 2:SUITE C
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035
Practice Address - Country:US
Practice Address - Phone:505-832-4011
Practice Address - Fax:505-832-0434
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1036225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH1865Medicaid
NMH1865Medicaid