Provider Demographics
NPI:1982791901
Name:FAVATA, KATHERINE A (CRNA)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:A
Last Name:FAVATA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:KIRK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:301 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-448-5440
Mailing Address - Fax:315-472-5010
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203
Practice Address - Country:US
Practice Address - Phone:315-448-5440
Practice Address - Fax:315-472-5010
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4844631367500000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB2782Medicare PIN