Provider Demographics
NPI:1790773901
Name:FABISIAK, DANUTA (PA)
Entity Type:Individual
Prefix:DR
First Name:DANUTA
Middle Name:
Last Name:FABISIAK
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 1:2110 58TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5660
Mailing Address - Country:US
Mailing Address - Phone:941-795-7222
Mailing Address - Fax:941-795-7335
Practice Address - Street 1:2110 58TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5660
Practice Address - Country:US
Practice Address - Phone:941-795-7222
Practice Address - Fax:941-795-7335
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL84742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261730700Medicaid
H14879Medicare UPIN
FL01817Medicare ID - Type Unspecified