Healthcare Provider Details

I. General information

NPI: 1245790062
Provider Name (Legal Business Name): MARINES FAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1682 NE PINE ISLAND RD
CAPE CORAL FL
33909-1756
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-1600
  • Fax: 239-468-7925
Mailing address:
  • Phone: 239-424-1600
  • Fax: 239-468-7925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME159605
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number040-P.A.
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: