Healthcare Provider Details

I. General information

NPI: 1255377768
Provider Name (Legal Business Name): PATRICK ANDREW FAVAZZA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

178/832 MOO7 HANG DONG
CHIANG MAI CHAING MAI
50230
TH

IV. Provider business mailing address

PO BOX 32 HANG DONG
CHIANG MAI CHAING MAI
50230
TH

V. Phone/Fax

Practice location:
  • Phone: 665-313-1175
  • Fax:
Mailing address:
  • Phone: 665-313-1175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: