Provider Demographics
NPI:1083634018
Name:FASANO, MARIA MABEL (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:MABEL
Last Name:FASANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR STE 306
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-9314
Practice Address - Country:US
Practice Address - Phone:570-522-4110
Practice Address - Fax:570-768-3911
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067300L207ZC0500X, 207ZP0101X, 207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA232809429OtherTRICARE
PA220025023OtherRAILROAD MEDICARE
PA321847OtherHEALTH AMERICA
PA17314940004Medicaid
PA540643OtherBLUE SHIELD
PA321847OtherHEALTH AMERICA
PA022842Medicare ID - Type Unspecified