Basic Information
| Provider Information | |||||||||
| NPI: | 1649240896 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANNIN | ||||||||
| FirstName: | ALICE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | WOT 12TH FLOOR ATTN. PHYSICIAN SERVICES | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083685529 | ||||||||
| FaxNumber: | 5083685530 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 PLANTATION ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085952000 | ||||||||
| FaxNumber: | 5088537149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1422 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 970024208 | 01 | RAILROAD MEDICARE | OTHER | 042472266 | 01 | THREE RIVERS | OTHER | 8301088 | 01 | EVERCARE | OTHER | 53324 | 01 | FALLON COMMUNITY HLTH PLN | OTHER | AP1638 | 01 | MEDICARE B | OTHER |