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General NPI Number Information
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NPI Number | 1720227309
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Entity Type | Individual
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Provider Name | CONSTANCE S FAIR PA
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Gender | Female
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Dates
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Enumeration Date | 02/05/2009
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Last Update Date | 06/22/2021
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Provider Practice Location Address
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Address Line | 3900 WOODLAND AVE
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City | PHILADELPHIA
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State | PA
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Zip | 19104-4551
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Country | US
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Telephone | 252-241-9898
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Fax |
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Provider Business Mailing Address
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Address Line | 401 WITLEY RD
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City | WYNNEWOOD
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State | PA
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Zip | 19096-2424
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Country | US
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Telephone | 252-241-9898
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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 | 0010-01710
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 364SP2800X
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Taxonomy Name | Perioperative Clinical Nurse Specialist
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License Number | MA060918
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License Number State | PA
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