Healthcare Provider Details

I. General information

NPI: 1184735342
Provider Name (Legal Business Name): JOSEPH S. FANELLI R-PA-C (PHYSICIAN AS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 EAST SHORE RD
GREAT NECK NY
11023
US

IV. Provider business mailing address

192 EAST SHORE RD
GREAT NECK NY
11023
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-4500
  • Fax: 516-487-7439
Mailing address:
  • Phone: 516-487-4500
  • Fax: 516-487-7439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0099421
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: