Provider Demographics
NPI:1003357005
Name:FASSE, DILLON JOHN (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:DILLON
Middle Name:JOHN
Last Name:FASSE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W290S4827 PARKE LN W
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-9047
Mailing Address - Country:US
Mailing Address - Phone:262-391-7952
Mailing Address - Fax:
Practice Address - Street 1:W156N9000 PILGRIM RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2272
Practice Address - Country:US
Practice Address - Phone:262-502-8752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1929-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer