Provider Demographics
NPI:1326290511
Name:FETZEK, DEVEN J (PA-C)
Entity Type:Individual
Prefix:
First Name:DEVEN
Middle Name:J
Last Name:FETZEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:995 PRINCE FREDERICK BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-5101
Mailing Address - Country:US
Mailing Address - Phone:443-351-3376
Mailing Address - Fax:
Practice Address - Street 1:995 PRINCE FREDERICK BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-5101
Practice Address - Country:US
Practice Address - Phone:443-351-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDPENDINGMedicare PIN