Provider Demographics
NPI:1275833931
Name:FEDULLO, PETER ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ANTHONY
Last Name:FEDULLO
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 1:11 4TH PL
Mailing Address - Street 2:APT 3L
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11231-3356
Mailing Address - Country:US
Mailing Address - Phone:585-727-4387
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014433363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical