Provider Demographics
NPI:1649207754
Name:FANNIE, MARCUS A (PA C)
Entity Type:Individual
Prefix:MR
First Name:MARCUS
Middle Name:A
Last Name:FANNIE
Suffix:
Gender:M
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 1:5820 CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15206-3710
Mailing Address - Country:US
Mailing Address - Phone:412-661-5500
Mailing Address - Fax:412-661-4760
Practice Address - Street 1:5820 CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15206-3710
Practice Address - Country:US
Practice Address - Phone:412-661-5500
Practice Address - Fax:412-661-4760
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002212L363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA002212LOtherMEDICAL LICENSE
PAMA002212LOtherMEDICAL LICENSE