Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT23961 | FL |
NPI | 1003099490 |
---|---|
Provider Name | Dr. Michael I. Fazio |
First Address | Bradenton, FL 34201-2091 |
Second Address | Bradenton, FL 34201-2091 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/12/2007 |
Last Update Date | 23/04/2012 |