Provider Demographics
NPI:1730650698
Name:FASOLO, GINA (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:
Last Name:FASOLO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-2248
Mailing Address - Country:US
Mailing Address - Phone:201-615-6601
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY647022367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered