Provider Demographics
NPI:1306223813
Name:FISUN, ANTHONY YAROSLAV (CRNP)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:YAROSLAV
Last Name:FISUN
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:MR
Other - First Name:YAROSLAV
Other - Middle Name:ANATOLEVICH
Other - Last Name:FISUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:2008 PRESIDENT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-2607
Mailing Address - Country:US
Mailing Address - Phone:215-200-0420
Mailing Address - Fax:
Practice Address - Street 1:2008 PRESIDENT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-2607
Practice Address - Country:US
Practice Address - Phone:215-200-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-04
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014633363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health