Provider Demographics
NPI:1205979689
Name:FENTON, DUANE LEE (PA-C)
Entity type:Individual
Prefix:
First Name:DUANE
Middle Name:LEE
Last Name:FENTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2608
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-2608
Mailing Address - Country:US
Mailing Address - Phone:970-263-2619
Mailing Address - Fax:970-263-2691
Practice Address - Street 1:2373 G RD STE 100
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505
Practice Address - Country:US
Practice Address - Phone:970-245-0484
Practice Address - Fax:970-241-1681
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPAL-2390363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00638187OtherRR MEDICARE PIN
CO85629375Medicaid
Q77145Medicare UPIN