Healthcare Provider Details

I. General information

NPI: 1528014008
Provider Name (Legal Business Name): JOHN A FAFINSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4648 W SPENCER ST
APPLETON WI
54914-9106
US

IV. Provider business mailing address

3420 JACKSON ST
OSHKOSH WI
54901-8144
US

V. Phone/Fax

Practice location:
  • Phone: 920-731-7557
  • Fax:
Mailing address:
  • Phone: 920-426-2211
  • Fax: 920-426-2231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number015101
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: