Provider Demographics
NPI:1134203037
Name:FEJKA, MICHAEL DAVID III (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:FEJKA
Suffix:III
Gender:M
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 1:700 SPRUCE ST
Mailing Address - Street 2:SUITE 305, GARFIELD-DUNCAN BLDG.
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-662-2626
Mailing Address - Fax:
Practice Address - Street 1:700 SPRUCE STREET
Practice Address - Street 2:SUITE 305
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106
Practice Address - Country:US
Practice Address - Phone:215-662-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051842363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ76045Medicare UPIN
PA107749Medicare PIN