Provider Demographics
NPI:1093464653
Name:FASANO, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:FASANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E 20TH ST STE 3FW1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-1310
Mailing Address - Country:US
Mailing Address - Phone:646-763-0342
Mailing Address - Fax:
Practice Address - Street 1:30 E 20TH ST STE 3FW1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-1310
Practice Address - Country:US
Practice Address - Phone:646-763-0342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY724775163WS0121X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0121XNursing Service ProvidersRegistered NursePlastic Surgery