Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | S1399 | TX |
N | 207R00000X | Internist | LL37667 | SC |
N | 111NI0900X | Internist | LL37667 | SC |
N | 208000000X | Pediatrician | LL37667 | SC |
NPI | 1508247024 |
---|---|
Provider Name | Dustin Fowler |
First Address | Waco, TX 76712-6630 |
Second Address | Waco, TX 76712-6630 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2015 |
Last Update Date | 28/07/2021 |