Basic Information
| Provider Information | |||||||||
| NPI: | 1104548221 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | ROLANDO | ||||||||
| MiddleName: | HUMBERTO | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22 VICTORY WAY | ||||||||
| Address2: | |||||||||
| City: | UPPER CHICHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190612470 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 22 VICTORY WAY | ||||||||
| Address2: | |||||||||
| City: | UPPER CHICHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190612470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2022 | ||||||||
| LastUpdateDate: | 09/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | SP026270 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP2300X | SP026270 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.