Provider Demographics
NPI:1295889418
Name:FENNEL, GARY ROSS (PA-C)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROSS
Last Name:FENNEL
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:15714 THISTLEBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-3226
Mailing Address - Country:US
Mailing Address - Phone:301-924-5388
Mailing Address - Fax:301-891-6313
Practice Address - Street 1:7600 CARROLL AVE
Practice Address - Street 2:WASHINGTON ADVENTIST HOSPITAL
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6367
Practice Address - Country:US
Practice Address - Phone:301-891-7600
Practice Address - Fax:301-891-6313
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MDC0000622363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical