Healthcare Provider Details

I. General information

NPI: 1083798532
Provider Name (Legal Business Name): JESSE T. FENGER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19245 7TH AVE NE
POULSBO WA
98370-6651
US

IV. Provider business mailing address

2512 WHEATON WAY
BREMERTON WA
98310-3399
US

V. Phone/Fax

Practice location:
  • Phone: 360-782-3500
  • Fax: 360-782-3540
Mailing address:
  • Phone: 360-782-3650
  • Fax: 360-782-3686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number728
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-10005297
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: