Provider Demographics
NPI:1598750374
Name:FOWLER, GAIL MARIE (PAC)
Entity type:Individual
Prefix:
First Name:GAIL
Middle Name:MARIE
Last Name:FOWLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-4880
Mailing Address - Country:US
Mailing Address - Phone:813-321-1786
Mailing Address - Fax:813-321-1787
Practice Address - Street 1:2001 SIESTA DR STE 201
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5200
Practice Address - Country:US
Practice Address - Phone:813-321-1786
Practice Address - Fax:813-321-1787
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106446363A00000X
CT000571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMF3542885OtherDEA
CT970001820Medicare PIN
290000571CT03OtherANTHEM BC BS