Healthcare Provider Details

I. General information

NPI: 1851528798
Provider Name (Legal Business Name): CAROL DIANE FAGUE RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 SOUTH AVE
ROCHESTER NY
14620-2733
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 655
ROCHESTER NY
14642-8655
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-6880
  • Fax:
Mailing address:
  • Phone: 585-341-6880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: