Basic Information
Provider Information | |||||||||
NPI: | 1962023093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FANTASIA | ||||||||
FirstName: | AL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RRT-NPS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 27 PARK ST | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026015230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 27 PARK ST | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026015230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088625000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2020 | ||||||||
LastUpdateDate: | 04/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2279C0205X | RT2863 |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Critical Care | 2279E0002X | RT2863 | MA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Emergency Care | 2279P3900X | RT2863 |   | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered | Neonatal/Pediatrics | 227900000X | RT2863 | MA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Respiratory Therapist, Registered |   |
No ID Information.