Provider Demographics
NPI:1356305205
Name:FENSKE, PHILIP D
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:D
Last Name:FENSKE
Suffix:
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 1:3457 LAKE TAHOE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-8910
Mailing Address - Country:US
Mailing Address - Phone:530-541-5262
Mailing Address - Fax:
Practice Address - Street 1:3457 LAKE TAHOE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8910
Practice Address - Country:US
Practice Address - Phone:530-541-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-15
Last Update Date:2013-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3289171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist