Provider Demographics
NPI:1659945350
Name:FALLACARO, JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:FALLACARO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CHARLES CT
Mailing Address - Street 2:
Mailing Address - City:E PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-6267
Mailing Address - Country:US
Mailing Address - Phone:631-880-0831
Mailing Address - Fax:
Practice Address - Street 1:3201 KINGS HWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2625
Practice Address - Country:US
Practice Address - Phone:718-252-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025654-01363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical