Provider Demographics
NPI:1245709500
Name:FABIANA, MICHAEL YOUNG
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:YOUNG
Last Name:FABIANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PASADA VALIENTE
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1983
Mailing Address - Country:US
Mailing Address - Phone:651-353-7369
Mailing Address - Fax:
Practice Address - Street 1:4 PASADA VALIENTE
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-1983
Practice Address - Country:US
Practice Address - Phone:651-353-7369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95170331163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse