Provider Demographics
NPI:1740394204
Name:FANO, MICHAEL (FNP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FANO
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:
Other - Last Name:FANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:105 - 04 SUTPHIN BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435
Mailing Address - Country:US
Mailing Address - Phone:718-725-5000
Mailing Address - Fax:718-725-5080
Practice Address - Street 1:105 - 04 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432
Practice Address - Country:US
Practice Address - Phone:855-681-8700
Practice Address - Fax:718-943-6788
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332757363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYLICENSE NUMBEROther332757