Provider Demographics
NPI:1285074278
Name:FAZAKAS, IDA (APRN)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:
Last Name:FAZAKAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:513-873-1269
Mailing Address - Fax:
Practice Address - Street 1:108 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:HAVERHILL
Practice Address - State:MA
Practice Address - Zip Code:01830-5210
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2366571363L00000X
NH071464-23363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH1285074278Medicare NSC