Healthcare Provider Details

I. General information

NPI: 1710896436
Provider Name (Legal Business Name): MICHAEL SHANE FAUTH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 PITTSFORD VICTOR RD
PITTSFORD NY
14534-3937
US

IV. Provider business mailing address

11 PONDVIEW DR
PITTSFORD NY
14534-9501
US

V. Phone/Fax

Practice location:
  • Phone: 585-325-1120
  • Fax:
Mailing address:
  • Phone: 585-353-3013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360758
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: