Healthcare Provider Details

I. General information

NPI: 1356364251
Provider Name (Legal Business Name): JOHN J FAZIO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HEROES WAY
RIVERHEAD NY
11901-2054
US

IV. Provider business mailing address

480 BEDFORD RD STE 4202
CHAPPAQUA NY
10514-1716
US

V. Phone/Fax

Practice location:
  • Phone: 631-548-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number375601
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WP0000X
TaxonomyPain Management Registered Nurse
License Number375601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: