Provider Demographics
NPI:1790853828
Name:FATULA, JUSTIN J (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:J
Last Name:FATULA
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 1:1250 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6224
Mailing Address - Country:US
Mailing Address - Phone:610-435-1003
Mailing Address - Fax:610-435-3184
Practice Address - Street 1:1250 S CEDAR CREST BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6224
Practice Address - Country:US
Practice Address - Phone:610-435-1003
Practice Address - Fax:610-435-3184
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA052857363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107389DWSMedicare PIN