Healthcare Provider Details

I. General information

NPI: 1720331671
Provider Name (Legal Business Name): RICHARD FASSOLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 06/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1932 S MAIN ST
EUREKA IL
61530-1666
US

IV. Provider business mailing address

5908 GREENVIEW RD
LISLE IL
60532-2904
US

V. Phone/Fax

Practice location:
  • Phone: 309-467-5000
  • Fax: 309-467-1500
Mailing address:
  • Phone: 815-474-2678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-000933
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: