Provider Demographics
NPI:1699921460
Name:FANO, JAMILYN (PA-C)
Entity type:Individual
Prefix:
First Name:JAMILYN
Middle Name:
Last Name:FANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMILYN
Other - Middle Name:
Other - Last Name:FLYZIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 75420
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-5420
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:STE 100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1757
Practice Address - Country:US
Practice Address - Phone:703-810-5223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
538695Medicare PIN
133512ZARVMedicare PIN