Provider Demographics
NPI:1699114512
Name:FAVAZZA, MATTHEW S (FNP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:FAVAZZA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HIGHLAND AVE
Mailing Address - Street 2:SUITE 24
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-3872
Mailing Address - Country:US
Mailing Address - Phone:978-462-1555
Mailing Address - Fax:978-462-1560
Practice Address - Street 1:21 HIGHLAND AVE
Practice Address - Street 2:SUITE 24
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3872
Practice Address - Country:US
Practice Address - Phone:978-462-1555
Practice Address - Fax:978-462-1560
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2276825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily