Provider Demographics
NPI:1396979993
Name:FENDER, TRACE ISAIAH (MD)
Entity type:Individual
Prefix:
First Name:TRACE
Middle Name:ISAIAH
Last Name:FENDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602373
Mailing Address - Street 2:MMA PSYCHIATRIC SERVICES
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-250-2833
Mailing Address - Fax:828-250-2932
Practice Address - Street 1:428 BILTMORE AVE
Practice Address - Street 2:MMA PSYCHIATRIC SERVICES
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4502
Practice Address - Country:US
Practice Address - Phone:828-213-4502
Practice Address - Fax:828-651-1575
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-017272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry