Provider Demographics
NPI:1801155890
Name:FASO, DWAIN R
Entity type:Individual
Prefix:
First Name:DWAIN
Middle Name:R
Last Name:FASO
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 1:15301 SPECTRUM DR
Mailing Address - Street 2:SUITE # 175
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4665
Mailing Address - Country:US
Mailing Address - Phone:972-980-9660
Mailing Address - Fax:972-980-9313
Practice Address - Street 1:15301 SPECTRUM DR
Practice Address - Street 2:SUITE # 175
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4665
Practice Address - Country:US
Practice Address - Phone:972-980-9660
Practice Address - Fax:972-980-9313
Is Sole Proprietor?:No
Enumeration Date:2012-05-10
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX206222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist