Healthcare Provider Details

I. General information

NPI: 1740875988
Provider Name (Legal Business Name): PHILIP FENN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4049 E WILLIAMS FIELD RD STE 101
GILBERT AZ
85295-3217
US

IV. Provider business mailing address

19924 E VIA DE ARBOLES
QUEEN CREEK AZ
85142-5028
US

V. Phone/Fax

Practice location:
  • Phone: 480-597-9497
  • Fax:
Mailing address:
  • Phone: 801-200-4674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8915
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: