Provider Demographics
NPI:1790234052
Name:FESKO, CORRIN M
Entity Type:Individual
Prefix:
First Name:CORRIN
Middle Name:M
Last Name:FESKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-410-8300
Mailing Address - Fax:814-410-8331
Practice Address - Street 1:315 LOCUST ST
Practice Address - Street 2:2ND FL
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15901-1651
Practice Address - Country:US
Practice Address - Phone:814-534-6750
Practice Address - Fax:814-534-6760
Is Sole Proprietor?:No
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP016585363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner