Healthcare Provider Details

I. General information

NPI: 1699767418
Provider Name (Legal Business Name): THOMAS A. FENGER PH.D., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16839 PARK PLACE ST
EAGLE RIVER AK
99577-7819
US

IV. Provider business mailing address

16839 PARK PLACE ST
EAGLE RIVER AK
99577-7819
US

V. Phone/Fax

Practice location:
  • Phone: 907-694-3303
  • Fax: 907-694-4773
Mailing address:
  • Phone: 907-694-3303
  • Fax: 907-694-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number423
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: