Provider Demographics
NPI:1346430576
Name:OSORIO, FANIO VIDAL (LPN)
Entity Type:Individual
Prefix:
First Name:FANIO
Middle Name:VIDAL
Last Name:OSORIO
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 MANOR AVE
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-1514
Mailing Address - Country:US
Mailing Address - Phone:518-326-6027
Mailing Address - Fax:
Practice Address - Street 1:163 MANOR AVE
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-1514
Practice Address - Country:US
Practice Address - Phone:518-326-6027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265483-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02190063Medicaid