MEDICARE: MR. ANDREW JAMES FAIRLEY CRPA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	CRPA-P-4690	NY

General Provider Information

NPI Number	:	1144819673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANDREW JAMES FAIRLEY CRPA

Provider Business Mailing Address
First Line	:	96 MOBILE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2128
Country	:	US
Telephone Number	:	347-756-0787
Fax Number	:

Provider Business Practice Location Address
First Line	:	96 MOBILE AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-2128
Country	:	US
Telephone Number	:	347-756-0787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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