Provider Demographics
NPI:1578050480
Name:FALLON, MARLEE ANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARLEE
Middle Name:ANNE
Last Name:FALLON
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 1:4402 MEDICAL CENTER DR STE 402
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-6626
Mailing Address - Country:US
Mailing Address - Phone:315-663-0005
Mailing Address - Fax:
Practice Address - Street 1:4402 MEDICAL CENTER DR STE 402
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6626
Practice Address - Country:US
Practice Address - Phone:315-663-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019993-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical