Provider Demographics
NPI:1588389464
Name:FAHNESTOCK, PHILIP
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:FAHNESTOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 WOODCOCK AVE
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443-9541
Mailing Address - Country:US
Mailing Address - Phone:304-240-6241
Mailing Address - Fax:
Practice Address - Street 1:186 WOODCOCK AVE
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443-9541
Practice Address - Country:US
Practice Address - Phone:304-240-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant