1093283863 NPI number — DANIEL EDWARD FENTON II FNP-C

Table of content: DANIEL EDWARD FENTON II FNP-C (NPI 1093283863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093283863 NPI number — DANIEL EDWARD FENTON II FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FENTON
Provider First Name:
DANIEL
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
II
Provider Credential Text:
FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093283863
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
824 HOUSTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRANTS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87020-3017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-315-1162
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 E ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87020-2115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-658-1347
Provider Business Practice Location Address Fax Number:
866-422-1014
Provider Enumeration Date:
11/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  RN-70242 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com