Provider Demographics
NPI:1346814720
Name:FANARA, ALYSSA GRACE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GRACE
Last Name:FANARA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6687 WIMBLEDON DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-9153
Mailing Address - Country:US
Mailing Address - Phone:317-694-6230
Mailing Address - Fax:
Practice Address - Street 1:9465 COUNSELORS ROW STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3817
Practice Address - Country:US
Practice Address - Phone:877-906-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2022-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant