Provider Demographics
NPI:1184735342
Name:FANELLI, JOSEPH S (R-PA-C (PHYSICIAN AS)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:S
Last Name:FANELLI
Suffix:
Gender:M
Credentials:R-PA-C (PHYSICIAN AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 EAST SHORE RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023
Mailing Address - Country:US
Mailing Address - Phone:516-487-4500
Mailing Address - Fax:516-487-7439
Practice Address - Street 1:192 EAST SHORE RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023
Practice Address - Country:US
Practice Address - Phone:516-487-4500
Practice Address - Fax:516-487-7439
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0099421363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical