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General NPI Number Information
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NPI Number | 1639721988
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Entity Type | Individual
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Provider Name | WILLIAM J. FAHRENBACH PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/16/2019
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Last Update Date | 12/10/2024
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Provider Practice Location Address
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Address Line | 6012 CARL ST
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City | FARMINGTON
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State | NM
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Zip | 87402-5266
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Country | US
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Telephone | 801-647-6101
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Fax |
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Provider Business Mailing Address
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Address Line | 2300 E 30TH ST BLDG D
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City | FARMINGTON
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State | NM
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Zip | 87401-8990
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Country | US
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Telephone | 801-647-6101
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2020-0096
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License Number State | NM
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