Healthcare Provider Details

I. General information

NPI: 1720313414
Provider Name (Legal Business Name): REBECCA FAICCO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2009
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 MIDDLE COUNTRY RD
SELDEN NY
11784-2516
US

IV. Provider business mailing address

500 RAFT AVE
HOLBROOK NY
11741-5912
US

V. Phone/Fax

Practice location:
  • Phone: 631-696-5437
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23-013506
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: