Provider Demographics
NPI:1922094937
Name:FAWKS, DAVID (ARNP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FAWKS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 E VENICE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-3191
Mailing Address - Country:US
Mailing Address - Phone:941-488-8884
Mailing Address - Fax:941-488-5554
Practice Address - Street 1:1790 E VENICE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-3191
Practice Address - Country:US
Practice Address - Phone:941-488-8884
Practice Address - Fax:941-488-5554
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1799382363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY7307OtherBCBS FLORIDA
FL2080449OtherCIGNA
FL7305448OtherAETNA
FL304079800Medicaid
FL283694-000OtherMAGELLAN
FLP00068887OtherRAILROAD MEDICARE
FL304079800Medicaid
FL283694-000OtherMAGELLAN