Provider Demographics
NPI:1013496892
Name:FAZZINO, DANIEL LOUIS (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LOUIS
Last Name:FAZZINO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 BARNHILL RD
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06798-2219
Mailing Address - Country:US
Mailing Address - Phone:203-217-1746
Mailing Address - Fax:
Practice Address - Street 1:76 BARNHILL RD
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:CT
Practice Address - Zip Code:06798-2219
Practice Address - Country:US
Practice Address - Phone:203-217-1746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-12
Last Update Date:2018-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55814363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical