Provider Demographics
NPI:1245790062
Name:FAYA, MARINES
Entity type:Individual
Prefix:
First Name:MARINES
Middle Name:
Last Name:FAYA
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1600
Mailing Address - Fax:239-468-7925
Practice Address - Street 1:1682 NE PINE ISLAND RD
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1756
Practice Address - Country:US
Practice Address - Phone:239-343-1600
Practice Address - Fax:239-468-7925
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME159605207R00000X
PR040-P.A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118437100Medicaid