Provider Demographics
NPI:1053402826
Name:FACKLER, DOUGLAS FLOYD (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:FLOYD
Last Name:FACKLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 PENNYRILE DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:EVANSVILLE VA OUTPATIENT CLINIC
Practice Address - Street 2:500 E. WALNUT
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713
Practice Address - Country:US
Practice Address - Phone:812-465-6202
Practice Address - Fax:812-465-6201
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00512363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical