Provider Demographics
NPI:1386004521
Name:FENNEWALD, NATHAN WADE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:WADE
Last Name:FENNEWALD
Suffix:
Gender:M
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 1:3181 SW SAM JACKSON PARK RD # OP31
Mailing Address - Street 2:ORTHOPEDICS & REHABILITATION DEPARTMENT
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:636-688-9260
Mailing Address - Fax:
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD # OP31
Practice Address - Street 2:ORTHOPEDICS & REHABILITATION DEPARTMENT
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:636-688-9260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA176237363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant