Provider Demographics
NPI:1033577754
Name:FERNON, JOHN JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:FERNON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PARISH RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:TX
Mailing Address - Zip Code:77632-7002
Mailing Address - Country:US
Mailing Address - Phone:409-745-9101
Mailing Address - Fax:
Practice Address - Street 1:149 PARISH RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:TX
Practice Address - Zip Code:77632-7002
Practice Address - Country:US
Practice Address - Phone:409-745-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661127363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily