Healthcare Provider Details

I. General information

NPI: 1609002344
Provider Name (Legal Business Name): JONATHAN EDWARD FASS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

053 MCKINLY LAB
NEWARK DE
19716
US

IV. Provider business mailing address

053 MCKINLY LAB
NEWARK DE
19716
US

V. Phone/Fax

Practice location:
  • Phone: 302-831-8893
  • Fax:
Mailing address:
  • Phone: 302-831-8893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberJ1-0002475
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: