Provider Demographics
NPI:1043364342
Name:FOWLER, JILL B (PA)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:B
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:150 PADUCAH DR
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2710
Mailing Address - Country:US
Mailing Address - Phone:304-455-8190
Mailing Address - Fax:304-455-8131
Practice Address - Street 1:150 PADUCAH DR
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2710
Practice Address - Country:US
Practice Address - Phone:304-455-8190
Practice Address - Fax:304-455-8131
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-04-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA14422Medicare PIN