Provider Demographics
NPI:1265260798
Name:FITISEMANU-BARTRAM, FIASILI (PRSS)
Entity type:Individual
Prefix:
First Name:FIASILI
Middle Name:
Last Name:FITISEMANU-BARTRAM
Suffix:
Gender:
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 10TH AVENUE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3579
Mailing Address - Country:US
Mailing Address - Phone:304-691-6381
Mailing Address - Fax:304-691-8591
Practice Address - Street 1:1600 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3657
Practice Address - Country:US
Practice Address - Phone:304-691-1100
Practice Address - Fax:304-691-1153
Is Sole Proprietor?:No
Enumeration Date:2024-07-25
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24-963175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist