Basic Information
| Provider Information | |||||||||
| NPI: | 1578547675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FABISZEWSKI | ||||||||
| FirstName: | NINA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WENNIGER | ||||||||
| OtherFirstName: | NINA | ||||||||
| OtherMiddleName: | DEBUY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5544 GREENWICH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Practice Location | |||||||||
| Address1: | 5544 GREENWICH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 0101049547 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 15982 | 01 | VA | SENTARA | OTHER | 890575Z | 05 | NC | MEDICAID | 139178 | 01 | VA | BCBS | OTHER | 15982 | 01 | VA | OPTIMA | OTHER | 7220928 | 05 | VA | MEDICAID | 300075983 | 01 | VA | RR MEDICARE | OTHER |