Provider Demographics
NPI:1609511427
Name:ORTIZ, FABIAN (PA-C)
Entity type:Individual
Prefix:
First Name:FABIAN
Middle Name:
Last Name:ORTIZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 80TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1234
Mailing Address - Country:US
Mailing Address - Phone:718-886-9000
Mailing Address - Fax:718-961-0666
Practice Address - Street 1:119 E FORDHAM RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5404
Practice Address - Country:US
Practice Address - Phone:718-886-9000
Practice Address - Fax:718-961-0666
Is Sole Proprietor?:No
Enumeration Date:2022-05-05
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9115015363A00000X
NY030974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant