Healthcare Provider Details

I. General information

NPI: 1326172669
Provider Name (Legal Business Name): BRIE FANTINI P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N MIDLAND AVE
NYACK NY
10960-1912
US

IV. Provider business mailing address

206 COVINGTON GREEN LN
PATTERSON NY
12563-2413
US

V. Phone/Fax

Practice location:
  • Phone: 845-348-8507
  • Fax: 845-348-6708
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number016196-1
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: