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General NPI Number Information
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NPI Number | 1407912389
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Entity Type | Organization
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Legal Business Name | JOHN RAYMOND FENYK, JR
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5647 DULUTH ST
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City | GOLDEN VALLEY
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State | MN
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Zip | 55422-4054
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Country | US
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Telephone | 763-545-8614
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Fax | 763-545-1935
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Provider Business Mailing Address
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Address Line | 5647 DULUTH ST
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City | GOLDEN VALLEY
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State | MN
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Zip | 55422-4054
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Country | US
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Telephone | 763-545-8614
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Fax | 763-545-1935
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Authorized Official
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Title or Position | BUSINESS OFFICE
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Name | MS. ANNETTE L SELVIG
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Credential |
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Telephone | 763-545-8614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 23247
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License Number State | MN
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