MEDICARE: DAVID C FAZEKAS

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	367500000X	Certified Registered Nurse Anesthetist	RN506354L	PA

General Provider Information

NPI Number	:	1972783850
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID C FAZEKAS

Provider Business Mailing Address
First Line	:	2703 MIRROR LAKE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5213
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2703 MIRROR LAKE DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28303-5213
Country	:	US
Telephone Number	:	610-282-5678
Fax Number	:

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

Provider Enumeration Date	:	11/08/2007
Last Update Date	:	04/22/2022

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