Provider Demographics
NPI:1750438875
Name:FERNAN, WILLIAM JAMES
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JAMES
Last Name:FERNAN
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 1:70 2ND ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-1509
Mailing Address - Country:US
Mailing Address - Phone:814-849-2844
Mailing Address - Fax:814-849-3425
Practice Address - Street 1:70 2ND ST
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-1509
Practice Address - Country:US
Practice Address - Phone:814-849-2844
Practice Address - Fax:814-849-3425
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002818103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1009170820001Medicaid
PA099648Medicare ID - Type Unspecified
PA1009170820001Medicaid