Provider Demographics
NPI:1922565001
Name:FABIAN, MATTHEW S (CRNA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:FABIAN
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CORLISS AVE APT 107
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2071
Mailing Address - Country:US
Mailing Address - Phone:607-763-6735
Mailing Address - Fax:607-763-6736
Practice Address - Street 1:57 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1476
Practice Address - Country:US
Practice Address - Phone:607-763-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY599246-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered