=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740275551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MUBASHER FAZAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2005
-----------------------------------------------------
Last Update Date | 06/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 W 12TH ST STE C
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16505-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-877-8730
-----------------------------------------------------
Fax | 814-877-8731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 W 12TH ST STE C
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16505-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-877-8730
-----------------------------------------------------
Fax | 814-877-8731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | MD067859L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 0101243795
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | D0068524
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207QS1201X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | D0068524
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207RS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | D0068524
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number | 0101243795
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------