Provider Demographics
NPI:1235987579
Name:FABIAN, MATTHEW RYAN
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RYAN
Last Name:FABIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 DOUGLAS AVENUE
Mailing Address - Street 2:
Mailing Address - City:TORONTO
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:M5M1H6
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:953 DANBY ROAD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-274-3011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-10
Last Update Date:2025-01-27
Deactivation Date:2025-01-10
Deactivation Code:
Reactivation Date:2025-01-27
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program