MEDICARE: MINERVA FAVORITO FNP

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	363LF0000X	Family Nurse Practitioner	335353	NY

General Provider Information

NPI Number	:	1316273790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINERVA FAVORITO FNP

Provider Business Mailing Address
First Line	:	3412 36TH ST
Second Line	:	SUITE 220
City	:	ASTORIA
State	:	NY
Zip	:	11106-1200
Country	:	US
Telephone Number	:	718-391-0611
Fax Number	:	347-761-3196

Provider Business Practice Location Address
First Line	:	3412 36TH ST
Second Line	:	SUITE 220
City	:	ASTORIA
State	:	NY
Zip	:	11106-1200
Country	:	US
Telephone Number	:	718-391-0611
Fax Number	:	347-761-3196

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

Provider Enumeration Date	:	10/20/2009
Last Update Date	:	10/20/2009

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