Healthcare Provider Details

I. General information

NPI: 1154074292
Provider Name (Legal Business Name): JASON DOMINIC FORTUNATO FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 ARCH ST STE G2
AKRON OH
44304-1430
US

IV. Provider business mailing address

36 MANNING RD
MOGADORE OH
44260-9524
US

V. Phone/Fax

Practice location:
  • Phone: 330-375-4100
  • Fax:
Mailing address:
  • Phone: 330-256-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0030571
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: