Provider Demographics
NPI:1508872276
Name:FADNESS, MARCY ANN (PA)
Entity Type:Individual
Prefix:
First Name:MARCY
Middle Name:ANN
Last Name:FADNESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:911 S. MILL STREET
Mailing Address - City:DECORAH
Mailing Address - State:IA
Mailing Address - Zip Code:52101-0096
Mailing Address - Country:US
Mailing Address - Phone:563-382-1200
Mailing Address - Fax:563-382-1211
Practice Address - Street 1:911 S MILL ST
Practice Address - Street 2:
Practice Address - City:DECORAH
Practice Address - State:IA
Practice Address - Zip Code:52101-2023
Practice Address - Country:US
Practice Address - Phone:563-382-1200
Practice Address - Fax:563-382-1211
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000914363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IB1248002Medicare PIN
IAR81066Medicare UPIN
IA36346OtherWELLMARK BC&BS IA
IA45043OtherWELLMARK BC&BS IA