Provider Demographics
NPI:1972991438
Name:FAVA, PATRICK JOHN JR (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JOHN
Last Name:FAVA
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6477 83RD PL
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-2434
Mailing Address - Country:US
Mailing Address - Phone:718-507-2961
Mailing Address - Fax:
Practice Address - Street 1:631 S COLLEGE AVE
Practice Address - Street 2:ATHLETIC TRAINING ROOM
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19716-2010
Practice Address - Country:US
Practice Address - Phone:302-831-8857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ3-00005242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer