Provider Demographics
NPI:1548206105
Name:COLLARELLI, FABIO (RPA-C)
Entity Type:Individual
Prefix:
First Name:FABIO
Middle Name:
Last Name:COLLARELLI
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HATFIELD LN
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6766
Mailing Address - Country:US
Mailing Address - Phone:845-294-3446
Mailing Address - Fax:845-294-4171
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:SUITE 201
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-294-3446
Practice Address - Fax:845-294-4171
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02280486Medicaid
4F8771Medicare ID - Type Unspecified
P39049Medicare UPIN