Provider Demographics
NPI:1407268972
Name:FENDER, STEPHEN (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:FENDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 64TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1800
Mailing Address - Country:US
Mailing Address - Phone:954-580-4084
Mailing Address - Fax:954-530-5096
Practice Address - Street 1:2964 N STATE ROAD 7
Practice Address - Street 2:SUITE 205
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-5715
Practice Address - Country:US
Practice Address - Phone:954-580-4080
Practice Address - Fax:954-580-4081
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIQ382ZMedicare PIN