Provider Demographics
NPI:1871811729
Name:FOWLKES, ELIZABETH ROSE (PA)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ROSE
Last Name:FOWLKES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:988102 NEBRASKA MEDICAL CTR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68198-8102
Mailing Address - Country:US
Mailing Address - Phone:402-559-6673
Mailing Address - Fax:402-559-8333
Practice Address - Street 1:987400 NEBRASKA MEDICAL CTR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68198-7400
Practice Address - Country:US
Practice Address - Phone:402-559-6673
Practice Address - Fax:402-559-8333
Is Sole Proprietor?:No
Enumeration Date:2010-05-16
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1501363AM0700X
IA002181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1871811729OtherWELLMARK BCBS OF IA
IA088710019Medicare PIN