Basic Information
| Provider Information | |||||||||
| NPI: | 1821076324 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATAKY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11050 MT BELVEDERE BLVD | ||||||||
| Address2: | USA MEDDAC ATTN: CREDENTIALS | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157729498 | ||||||||
| Practice Location | |||||||||
| Address1: | 11050 MT BELVEDERE BLVD | ||||||||
| Address2: | USA MEDDAC ATTN: CREDENTIALS | ||||||||
| City: | FORT DRUM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 136025004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157724025 | ||||||||
| FaxNumber: | 3157729498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.