Provider Demographics
NPI:1275571507
Name:FENNELL, PATRICK STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:STANLEY
Last Name:FENNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 MISSKELLY DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5817
Mailing Address - Country:US
Mailing Address - Phone:919-510-0637
Mailing Address - Fax:
Practice Address - Street 1:3909 SUNSET RIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6667
Practice Address - Country:US
Practice Address - Phone:919-788-0505
Practice Address - Fax:919-788-0519
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400787208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8931567Medicaid
NC8931567Medicaid