Provider Demographics
NPI:1992986350
Name:FOGEL, JENNY IDA (PA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:IDA
Last Name:FOGEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JENNY
Other - Middle Name:IDA
Other - Last Name:TANENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3031 FALLSTAFF RD UNIT 307C
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-5014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3031 FALLSTAFF RD UNIT 307C
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-5014
Practice Address - Country:US
Practice Address - Phone:443-525-5576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC2156OtherMD LICENSE NUMBER