Healthcare Provider Details

I. General information

NPI: 1831140268
Provider Name (Legal Business Name): PETER ALLEN FENN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 LANIER ST.
BUIES CREEK NC
27506-0565
US

IV. Provider business mailing address

101 COUNTRY MEADOW LN.
COATS NC
27521-9556
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-1559
  • Fax: 910-893-1559
Mailing address:
  • Phone: 910-897-2354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number100867
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100867
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: