Healthcare Provider Details

I. General information

NPI: 1215226493
Provider Name (Legal Business Name): AMELIA THERESA WACK FIASTRO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIRCLIFF WAY
JACKSONVILLE FL
32204-4748
US

IV. Provider business mailing address

1525 W CYPRESS CREEK RD
FT. LAUDERDALE FL
33309
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME133225
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: