Provider Demographics
NPI:1073094975
Name:FASANO, WENDY (PA)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1519 N TOWN EAST BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150
Mailing Address - Country:US
Mailing Address - Phone:972-270-5549
Mailing Address - Fax:972-270-5558
Practice Address - Street 1:1645 N TOWN EAST BLVD STE 174
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4146
Practice Address - Country:US
Practice Address - Phone:972-270-5549
Practice Address - Fax:972-270-5558
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant