Healthcare Provider Details

I. General information

NPI: 1922238195
Provider Name (Legal Business Name): KENNETH ERVINE FATKIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 W WARM SPRINGS RD STE 102
HENDERSON NV
89014-7632
US

IV. Provider business mailing address

1485 W WARM SPRINGS RD STE 102
HENDERSON NV
89014-7632
US

V. Phone/Fax

Practice location:
  • Phone: 702-435-7987
  • Fax: 702-435-7616
Mailing address:
  • Phone: 702-435-7987
  • Fax: 702-435-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number1008
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: