Provider Demographics
NPI:1336117233
Name:FALTYN, GREGORY R (R-PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:FALTYN
Suffix:
Gender:M
Credentials:R-PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 UNION AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-1844
Mailing Address - Country:US
Mailing Address - Phone:315-703-5047
Mailing Address - Fax:315-703-5079
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-448-5111
Practice Address - Fax:315-637-7907
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003578-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02743066Medicaid
NY02743066Medicaid
NYP00651083Medicare PIN
NYPA1751Medicare PIN