Provider Demographics
NPI:1083265474
Name:FAZEKAS, DARELL
Entity Type:Individual
Prefix:
First Name:DARELL
Middle Name:
Last Name:FAZEKAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2272 HIGHTRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-9093
Mailing Address - Country:US
Mailing Address - Phone:425-773-2392
Mailing Address - Fax:
Practice Address - Street 1:2272 HIGHTRAIL WAY
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-9093
Practice Address - Country:US
Practice Address - Phone:425-773-2392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider