Provider Demographics
NPI:1740875988
Name:FENN, PHILIP
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:FENN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19924 E VIA DE ARBOLES
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5028
Mailing Address - Country:US
Mailing Address - Phone:801-200-4674
Mailing Address - Fax:
Practice Address - Street 1:4049 E WILLIAMS FIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-3217
Practice Address - Country:US
Practice Address - Phone:480-597-9497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
AZ8915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant