Provider Demographics
NPI:1417144536
Name:FANCO, MARISSA PASCO (PT)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:PASCO
Last Name:FANCO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 SONGBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-4863
Mailing Address - Country:US
Mailing Address - Phone:310-906-9710
Mailing Address - Fax:424-558-8858
Practice Address - Street 1:403 N PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-2839
Practice Address - Country:US
Practice Address - Phone:310-798-8777
Practice Address - Fax:310-798-8783
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2010-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 33856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPTIN#WPT324618OtherMEDICARE