Provider Demographics
NPI:1417521006
Name:FAHEY, JAMES GRANT (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:GRANT
Last Name:FAHEY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7115 GREENBACK LN
Practice Address - Street 2:FL 2
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95621-6133
Practice Address - Country:US
Practice Address - Phone:916-536-3620
Practice Address - Fax:916-536-3541
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59574363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty