Provider Demographics
NPI:1023765708
Name:FENNELL, MICHAEL JAMES II (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:JAMES
Last Name:FENNELL
Suffix:II
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:9673 GARDEN WALK
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3055 SOUTHWESTERN BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1231
Practice Address - Country:US
Practice Address - Phone:716-675-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY028057-01363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant