Basic Information
| Provider Information | |||||||||
| NPI: | 1124300959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORNASERO | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | LECI | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S. PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 W LEGION RD | ||||||||
| Address2: | |||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922277780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603513333 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 W LEGION RD | ||||||||
| Address2: | |||||||||
| City: | BRAWLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922277780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603513333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2011 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA21802 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.