Provider Demographics
NPI:1396717492
Name:FAISON, DOUGLAS LEE (PA-C)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:LEE
Last Name:FAISON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DOUGLAS
Other - Middle Name:LEE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:23759 MOONGLOW CT
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-4517
Mailing Address - Country:US
Mailing Address - Phone:619-524-0789
Mailing Address - Fax:760-788-2546
Practice Address - Street 1:35000 GUADALCANAL AVE
Practice Address - Street 2:BRANCH MEDICAL CLINIC, MCRD BLD 596
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-0789
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1032153363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical