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NPI Code Detail

MEDICARE: MR. FORREST T FORNASH PA

MEDICARE: MR. FORREST T FORNASH PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363AM0700XMedical Physician Assistant1973OH

General Provider Information

NPI Number : 1164494290
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. FORREST T FORNASH PA
Provider Business Mailing Address
First Line : 14 TREVILLA CT
Second Line :
City : FORT THOMAS
State : KY
Zip : 41075-4025
Country : US
Telephone Number : 937-903-1868
Fax Number :
Provider Business Practice Location Address
First Line : 215 S ALLISON AVE
Second Line :
City : XENIA
State : OH
Zip : 45385-3694
Country : US
Telephone Number : 937-903-1868
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/02/2006
Last Update Date : 04/05/2013

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