MEDICARE: NICOLE J FANARJIAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VG0400X	Gynecology Physician	ME107878	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588674576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE J FANARJIAN M.D.

Provider Business Mailing Address
First Line	:	2919 W SWANN AVE STE 303
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4051
Country	:	US
Telephone Number	:	813-569-0740
Fax Number	:	813-864-7603

Provider Business Practice Location Address
First Line	:	2919 W SWANN AVE STE 303
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4051
Country	:	US
Telephone Number	:	813-569-0740
Fax Number	:	813-864-7603

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	03/01/2023

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