Provider Demographics
NPI:1376265900
Name:FAZZONE, CLAIRE NICOLE
Entity Type:Individual
Prefix:
First Name:CLAIRE
Middle Name:NICOLE
Last Name:FAZZONE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CLAIRE
Other - Middle Name:NICOLE
Other - Last Name:FAZZONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:901 W BEN WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-6903
Mailing Address - Country:US
Mailing Address - Phone:210-413-5614
Mailing Address - Fax:
Practice Address - Street 1:901 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6903
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant