Provider Demographics
NPI:1164494290
Name:FORNASH, FORREST T (PA)
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:T
Last Name:FORNASH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:FORREST
Other - Middle Name:T
Other - Last Name:FORNASH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:14 TREVILLA CT
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-4025
Mailing Address - Country:US
Mailing Address - Phone:937-903-1868
Mailing Address - Fax:
Practice Address - Street 1:215 S ALLISON AVE
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-3694
Practice Address - Country:US
Practice Address - Phone:937-903-1868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1973363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical