Healthcare Provider Details

I. General information

NPI: 1023401783
Provider Name (Legal Business Name): DAVID A. FENWICK P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
CINCINNATI OH
45242-4402
US

IV. Provider business mailing address

10506 MONTGOMERY RD SUITE 209
CINCINNATI OH
45242-4487
US

V. Phone/Fax

Practice location:
  • Phone: 514-865-1111
  • Fax:
Mailing address:
  • Phone: 513-865-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.004256
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: