Provider Demographics
NPI:1881044006
Name:FOWLER, TRISTAN ROSS PEREGRINO (DO)
Entity type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:ROSS PEREGRINO
Last Name:FOWLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5043
Mailing Address - Country:US
Mailing Address - Phone:573-472-7535
Mailing Address - Fax:573-472-7787
Practice Address - Street 1:1013 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5043
Practice Address - Country:US
Practice Address - Phone:573-472-7535
Practice Address - Fax:573-472-7787
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-18
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-43441207V00000X
MI5101022338207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology