Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | MA063090 | PA |
NPI | 1578226387 |
---|---|
Provider Name | Nico Edward Vasquez |
First Address | Danville, PA 17822-4903 |
Second Address | Scranton, PA 18508-2572 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/10/2021 |
Last Update Date | 15/12/2021 |