Individual
ALICE A FANNIN
Active
Sole proprietor
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
630 PLANTATION ST, WORCESTER, MA 01605
(508) 595-2000
(508) 853-7149
Mailing address
630 PLANTATION ST, WOT 12TH FLOOR ATTN. PHYSICIAN SERVICES, WORCESTER, MA 01605
(508) 368-5529
(508) 368-5530
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
1422
MA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
042472266
THREE RIVERS
—
01
—
53324
FALLON COMMUNITY HLTH PLN
—
01
—
8301088
EVERCARE
—
01
—
970024208
RAILROAD MEDICARE
—
01
—
AP1638
MEDICARE B
—
Enumeration date
01/23/2006
Last updated
07/08/2007
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