Basic Information
| Provider Information | |||||||||
| NPI: | 1013501295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENNICA | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | AGACNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 ROSEMARY CT | ||||||||
| Address2: | |||||||||
| City: | MANORVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119492818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312782927 | ||||||||
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| Practice Location | |||||||||
| Address1: | 424 E 34TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100164901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122637300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2021 | ||||||||
| LastUpdateDate: | 02/27/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 431824 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.