Provider Demographics
NPI:1679162911
Name:FOWLER, BRENT J (CSFA)
Entity type:Individual
Prefix:MR
First Name:BRENT
Middle Name:J
Last Name:FOWLER
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3497 ABBEY WAY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30507-5045
Mailing Address - Country:US
Mailing Address - Phone:770-530-2732
Mailing Address - Fax:
Practice Address - Street 1:1240 JESSE JEWELL PKWY SE STE 360
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3861
Practice Address - Country:US
Practice Address - Phone:770-534-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant