Provider Demographics
NPI:1689689341
Name:FASCIANA, GUY MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:MICHAEL
Last Name:FASCIANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURYEA
Mailing Address - State:PA
Mailing Address - Zip Code:18642-1325
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:605 MAIN ST
Practice Address - Street 2:
Practice Address - City:DURYEA
Practice Address - State:PA
Practice Address - Zip Code:18642-1325
Practice Address - Country:US
Practice Address - Phone:570-457-1110
Practice Address - Fax:570-457-2950
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039471L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001004013Medicaid
441657Medicare ID - Type Unspecified
PA001004013Medicaid