Provider Demographics
NPI:1821076324
Name:PATAKY, GREGORY JOHN (APA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JOHN
Last Name:PATAKY
Suffix:
Gender:M
Credentials:APA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC ATTN: CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC ATTN: CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN