Provider Demographics
NPI:1447268271
Name:FOWLER, DIANA M (PA/AA)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:M
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PA/AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002468367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001578BMedicaid
GA100001578DMedicaid
GA970026294OtherRAILROAD MEDICARE
GA100001578CMedicaid
GA336920OtherWELLCARE
GA100001578AMedicaid
GA100001578AMedicaid
GA336920OtherWELLCARE
S99386Medicare UPIN