Basic Information
| Provider Information | |||||||||
| NPI: | 1972540987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREVELE | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 725 | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133260725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473334 | ||||||||
| FaxNumber: | 6075476551 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473334 | ||||||||
| FaxNumber: | 6075476551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 03/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003290 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02141606 | 05 | NY | MEDICAID |