Provider Demographics
NPI:1427068782
Name:FANOS, KATHLEEN H (DO)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:H
Last Name:FANOS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-6626
Mailing Address - Country:US
Mailing Address - Phone:716-488-1877
Mailing Address - Fax:716-488-1986
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:SUITE 150
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6626
Practice Address - Country:US
Practice Address - Phone:716-484-3776
Practice Address - Fax:716-484-3777
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18127207R00000X
NY200860207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400168920OtherMEDICARE PTAN
NY2275670Medicaid