Provider Demographics
NPI:1184675829
Name:FASSY, LYNN R (MD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:R
Last Name:FASSY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-2364
Mailing Address - Country:US
Mailing Address - Phone:941-926-4770
Mailing Address - Fax:941-923-2520
Practice Address - Street 1:3945 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233-2364
Practice Address - Country:US
Practice Address - Phone:941-926-4770
Practice Address - Fax:941-923-2520
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME64532208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL18990XMedicare ID - Type UnspecifiedMEDICIARE
FLE69052Medicare UPIN