Provider Demographics
NPI:1649240896
Name:FANNIN, ALICE A (PA)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:A
Last Name:FANNIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN. PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:630 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-595-2000
Practice Address - Fax:508-853-7149
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970024208OtherRAILROAD MEDICARE
042472266OtherTHREE RIVERS
8301088OtherEVERCARE
53324OtherFALLON COMMUNITY HLTH PLN
AP1638OtherMEDICARE B
AP1638OtherMEDICARE B
042472266OtherTHREE RIVERS