Provider Demographics
NPI:1902314412
Name:FAVATA, RYAN PAUL (LPN)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:PAUL
Last Name:FAVATA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WIDGER RD
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-9751
Mailing Address - Country:US
Mailing Address - Phone:585-694-5342
Mailing Address - Fax:
Practice Address - Street 1:1 WIDGER RD
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-9751
Practice Address - Country:US
Practice Address - Phone:585-694-5342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329330164X00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse