Provider Demographics
NPI:1245448513
Name:FANECK, KRISTAN NICOLE (PAC)
Entity type:Individual
Prefix:MS
First Name:KRISTAN
Middle Name:NICOLE
Last Name:FANECK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:KRISTAN
Other - Middle Name:NICOLE
Other - Last Name:HOSAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:STE 205
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-402-9116
Practice Address - Fax:610-402-9610
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant