Individual
MARY BETH FASANO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
200 HAWKINS DR, IOWA CITY, IA 52242-1009
(319) 356-3692
(319) 356-8280
Mailing address
200 HAWKINS DR, IOWA CITY, IA 52242-1009
(319) 356-3692
(319) 356-8280
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
35451
IA
207RA0201X
Allergy & Immunology (Internal Medicine) Physician
Primary
35451
IA
208000000X
Pediatrics Physician
35451
IA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04197
WELLMARK BCBS
IA
05
—
0432013
—
IA
Enumeration date
10/13/2005
Last updated
11/29/2007
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