Healthcare Provider Details

I. General information

NPI: 1932743432
Provider Name (Legal Business Name): LISA KATHERINE FASONE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 11TH CT
VERO BEACH FL
32960-5012
US

IV. Provider business mailing address

3450 11TH CT
VERO BEACH FL
32960-5012
US

V. Phone/Fax

Practice location:
  • Phone: 877-463-2010
  • Fax:
Mailing address:
  • Phone: 877-463-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121981
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: