=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245790062
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARINES FAYA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2019
-----------------------------------------------------
Last Update Date | 08/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1682 NE PINE ISLAND RD
-----------------------------------------------------
City | CAPE CORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33909-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-343-1600
-----------------------------------------------------
Fax | 239-468-7925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2147
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33902-2147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-424-1600
-----------------------------------------------------
Fax | 239-468-7925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME159605
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 040-P.A.
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------