Provider Demographics
NPI:1588664429
Name:FASON, JANET TIRRELL (DO)
Entity Type:Individual
Prefix:DR
First Name:JANET
Middle Name:TIRRELL
Last Name:FASON
Suffix:
Gender:F
Credentials:DO
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 1085
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-1085
Mailing Address - Country:US
Mailing Address - Phone:770-486-8206
Mailing Address - Fax:770-486-8105
Practice Address - Street 1:105 CARRIAGE OAKS DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-1686
Practice Address - Country:US
Practice Address - Phone:770-486-8206
Practice Address - Fax:770-486-8105
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA048773OtherLICENSE
GA000963784Medicaid
GA08BBXFGMedicare ID - Type Unspecified