Provider Demographics
NPI:1588065502
Name:FENN, DUANE J (PA-C)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:J
Last Name:FENN
Suffix:
Gender:M
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 1:370 E VIRGINIA AVE
Mailing Address - Street 2:100
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1214
Mailing Address - Country:US
Mailing Address - Phone:602-258-4788
Mailing Address - Fax:
Practice Address - Street 1:370 E VIRGINIA AVE
Practice Address - Street 2:100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1214
Practice Address - Country:US
Practice Address - Phone:602-258-4788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5853363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ200166Medicare PIN