Basic Information
| Provider Information | |||||||||
| NPI: | 1871811729 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOWLKES | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 988102 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681988102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596673 | ||||||||
| FaxNumber: | 4025598333 | ||||||||
| Practice Location | |||||||||
| Address1: | 987400 NEBRASKA MEDICAL CTR | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681987400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025596673 | ||||||||
| FaxNumber: | 4025598333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2010 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1501 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 002181 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1871811729 | 01 | IA | WELLMARK BCBS OF IA | OTHER |