Provider Demographics
NPI:1164782769
Name:FENN, RICHARD E (CRNA)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
Last Name:FENN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1338 PHAY AVE
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-2302
Mailing Address - Country:US
Mailing Address - Phone:719-285-2434
Mailing Address - Fax:719-285-2101
Practice Address - Street 1:1338 PHAY AVE
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-2302
Practice Address - Country:US
Practice Address - Phone:719-285-2434
Practice Address - Fax:719-285-2101
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO204743367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered