Provider Demographics
NPI:1770764482
Name:FARRETTA, EDWARD P
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:P
Last Name:FARRETTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 E MAIN ST STE 18
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-8006
Mailing Address - Country:US
Mailing Address - Phone:480-947-0203
Mailing Address - Fax:480-324-0908
Practice Address - Street 1:4930 E MAIN ST STE 18
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-8006
Practice Address - Country:US
Practice Address - Phone:480-947-0203
Practice Address - Fax:480-324-0908
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-21
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4305660001Medicare NSC