Provider Demographics
NPI:1659920767
Name:FALLACARO, JUSTIN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:FALLACARO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 HIGH RIDGE PARK FL 2
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1332
Mailing Address - Country:US
Mailing Address - Phone:203-869-1145
Mailing Address - Fax:203-618-1721
Practice Address - Street 1:3141 ROUTE 9W
Practice Address - Street 2:
Practice Address - City:NEW WINDSOR
Practice Address - State:NY
Practice Address - Zip Code:12553-6709
Practice Address - Country:US
Practice Address - Phone:845-534-5768
Practice Address - Fax:845-686-9001
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY024728363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY06045005Medicaid