Healthcare Provider Details

I. General information

NPI: 1588664429
Provider Name (Legal Business Name): JANET TIRRELL FASON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CARRIAGE OAKS DR
TYRONE GA
30290-1686
US

IV. Provider business mailing address

PO BOX 1085
TYRONE GA
30290-1085
US

V. Phone/Fax

Practice location:
  • Phone: 770-486-8206
  • Fax: 770-486-8105
Mailing address:
  • Phone: 770-486-8206
  • Fax: 770-486-8105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number048773
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: