Provider Demographics
NPI:1114294055
Name:FADDOUL, EBTISAM (PA-C)
Entity Type:Individual
Prefix:
First Name:EBTISAM
Middle Name:
Last Name:FADDOUL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 HOSPITAL PLZ STE 501
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-276-4400
Mailing Address - Fax:203-276-4401
Practice Address - Street 1:29 HOSPITAL PLZ STE 501
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-4400
Practice Address - Fax:203-276-4401
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015255-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant