MEDICARE: MS. CAROL FABIAN APRN, BC

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	363L00000X	Nurse Practitioner	26NN09868200	NJ

General Provider Information

NPI Number	:	1821088683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL FABIAN APRN, BC

Provider Business Mailing Address
First Line	:	123 PINE DR
Second Line	:
City	:	BLACK RIVER
State	:	NY
Zip	:	13612-2110
Country	:	US
Telephone Number	:	315-772-8422
Fax Number	:	315-772-1689

Provider Business Practice Location Address
First Line	:	SECOND ST AND SOUTH RIVA RIDGE BLVD
Second Line	:	CONNER TROOP MEMORIAL CLINIC
City	:	FT DRUM
State	:	NY
Zip	:	13602
Country	:	US
Telephone Number	:	315-772-8422
Fax Number	:	315-772-1689

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

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	07/08/2007

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