Provider Demographics
NPI:1720227309
Name:FAIR, CONSTANCE S (PA)
Entity Type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:S
Last Name:FAIR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 WITLEY RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-2424
Mailing Address - Country:US
Mailing Address - Phone:252-241-9898
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:252-241-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01710363A00000X
PAMA060918364SP2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant