Provider Demographics
NPI:1437300605
Name:FASANYA, PETER ADEKOLA (PT,DPT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ADEKOLA
Last Name:FASANYA
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 ELZEY AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-1532
Mailing Address - Country:US
Mailing Address - Phone:718-736-4632
Mailing Address - Fax:516-352-4548
Practice Address - Street 1:91 ELZEY AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-1532
Practice Address - Country:US
Practice Address - Phone:718-736-4632
Practice Address - Fax:516-352-4548
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027197172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker