Provider Demographics
NPI:1730557505
Name:MINAYA CORREA, FAUSTO
Entity type:Individual
Prefix:
First Name:FAUSTO
Middle Name:
Last Name:MINAYA CORREA
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 1:540 BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-2522
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:203-298-4185
Practice Address - Street 1:540 BISHOP DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-2522
Practice Address - Country:US
Practice Address - Phone:203-553-9696
Practice Address - Fax:203-298-4185
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2016-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144151246XS1301X, 246X00000X
246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246X00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist Cardiovascular
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic