Provider Demographics
NPI:1972160505
Name:FENNER, DEVON E (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DEVON
Middle Name:E
Last Name:FENNER
Suffix:
Gender:F
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 1:4100 CAMPUS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6139
Mailing Address - Country:US
Mailing Address - Phone:810-488-5795
Mailing Address - Fax:
Practice Address - Street 1:750 LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2104
Practice Address - Country:US
Practice Address - Phone:810-488-5795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-20
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant