Provider Demographics
NPI:1962023093
Name:FANTASIA, AL (RRT-NPS)
Entity type:Individual
Prefix:
First Name:AL
Middle Name:
Last Name:FANTASIA
Suffix:
Gender:M
Credentials:RRT-NPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-5230
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27 PARK ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5230
Practice Address - Country:US
Practice Address - Phone:508-862-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RT28632279C0205X, 2279P3900X
MART28632279E0002X, 227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered
No2279C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredCritical Care
No2279E0002XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredEmergency Care
No2279P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, RegisteredNeonatal/Pediatrics