Provider Demographics
NPI:1477012631
Name:FARGO, DIANE LYNN
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:LYNN
Last Name:FARGO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DIANE
Other - Middle Name:LYNN
Other - Last Name:MASTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2441 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2001
Mailing Address - Country:US
Mailing Address - Phone:607-770-6297
Mailing Address - Fax:607-766-9582
Practice Address - Street 1:2441 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2001
Practice Address - Country:US
Practice Address - Phone:607-770-6297
Practice Address - Fax:607-766-9582
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009393156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician