Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LC1500X | Nurse Practitioner - Community Health | 901535 | MS |
NPI | 1386197697 |
---|---|
Provider Name | Scott Fowler |
First Address | Purvis, MS 39475-6051 |
Second Address | Laurel, MS 39440-4312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2016 |
Last Update Date | 31/01/2017 |