Provider Demographics
NPI:1104431576
Name:FENCHEL, GREGORY ALLAN JR (CRNA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLAN
Last Name:FENCHEL
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 HILLSIDE RD APT 1101
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-8316
Mailing Address - Country:US
Mailing Address - Phone:505-306-6869
Mailing Address - Fax:
Practice Address - Street 1:1501 S COULTER ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1770
Practice Address - Country:US
Practice Address - Phone:806-354-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-12
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX1011950367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program