Provider Demographics
NPI:1922739531
Name:FARGO, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:FARGO
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 1:1 ATWELL RD
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13326-1301
Mailing Address - Country:US
Mailing Address - Phone:607-547-3456
Mailing Address - Fax:607-547-5196
Practice Address - Street 1:597 CO RD 54
Practice Address - Street 2:
Practice Address - City:CHERRY VALL
Practice Address - State:NY
Practice Address - Zip Code:13214-1302
Practice Address - Country:US
Practice Address - Phone:607-264-3265
Practice Address - Fax:607-264-3458
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY030992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program