Provider Demographics
NPI:1033815113
Name:FAZENBAKER, LAUREN ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ANN
Last Name:FAZENBAKER
Suffix:
Gender:F
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 1:19790 WELLEN PK BLVD
Mailing Address - Street 2:SUITE 201B
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34293
Mailing Address - Country:US
Mailing Address - Phone:941-777-7771
Mailing Address - Fax:
Practice Address - Street 1:19790 WELLEN PARK BLVD
Practice Address - Street 2:SUITE 201B
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34293
Practice Address - Country:US
Practice Address - Phone:941-777-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-01
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9117443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant