Basic Information
| Provider Information | |||||||||
| NPI: | 1295889418 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNEL | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | ROSS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15714 THISTLEBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208533226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019245388 | ||||||||
| FaxNumber: | 3018916313 | ||||||||
| Practice Location | |||||||||
| Address1: | 7600 CARROLL AVE | ||||||||
| Address2: | WASHINGTON ADVENTIST HOSPITAL | ||||||||
| City: | TAKOMA PARK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209126367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018917600 | ||||||||
| FaxNumber: | 3018916313 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | C0000622 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.