Provider Demographics
NPI:1588861371
Name:JOWDY, FRED JOHN (CRNA)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:JOHN
Last Name:JOWDY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 BLUFF AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3862
Mailing Address - Country:US
Mailing Address - Phone:800-394-4445
Mailing Address - Fax:706-396-3252
Practice Address - Street 1:2204 IRONWOOD PL STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2662
Practice Address - Country:US
Practice Address - Phone:208-765-8585
Practice Address - Fax:208-765-8486
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAIT40000981367500000X
IDRNA-696A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807814700Medicaid