Provider Demographics
NPI:1831140268
Name:FENN, PETER ALLEN (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:ALLEN
Last Name:FENN
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 1:101 COUNTRY MEADOW LN.
Mailing Address - Street 2:
Mailing Address - City:COATS
Mailing Address - State:NC
Mailing Address - Zip Code:27521-9556
Mailing Address - Country:US
Mailing Address - Phone:910-897-2354
Mailing Address - Fax:
Practice Address - Street 1:129 LANIER ST.
Practice Address - Street 2:
Practice Address - City:BUIES CREEK
Practice Address - State:NC
Practice Address - Zip Code:27506-0565
Practice Address - Country:US
Practice Address - Phone:910-893-1559
Practice Address - Fax:910-893-1559
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100867363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2743749Medicare ID - Type Unspecified