Provider Demographics
NPI:1467427443
Name:FASCIANO, JAMES ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALFRED
Last Name:FASCIANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-1100
Mailing Address - Fax:
Practice Address - Street 1:3901 HOYT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4918
Practice Address - Country:US
Practice Address - Phone:425-339-5456
Practice Address - Fax:425-303-3091
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12953207Q00000X
CAG84986207Q00000X
WAMD60697846207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG84986OtherCA STATE LICENSE
NV12953OtherNEVADA STATE LICENSE
NV004716904Medicaid
CA00G849860Medicaid
WA2069525Medicaid
WAG8960335Medicare PIN
WAG8956081Medicare PIN
CA00G849860Medicaid