| Doctor Name: | MISS AUTUMN LECI FORNASERO |
| NPI Number: | 1124300959 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | M.S. PA-C |
| License Number: | PA21802 |
| Business Practice Address: | 207 W Legion Rd Brawley, CA - 922277780 |
| Business Phone Number: | 7603513333 |
| Business Fax Number: | |
| Mailing Address: | 207 W Legion Rd, BRAWLEY |
| State: | CA |
| Postal Code: | 922277780 |
| Phone Number: | 7603513333 |
| Fax Number: | |
| NPI Enumeration Date: | 09/19/2011 |
| NPI Last Update Date: | 09/19/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | PA21802 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |