Provider Demographics
NPI:1033305107
Name:VLASE, MADALINA ANCA (PA)
Entity Type:Individual
Prefix:
First Name:MADALINA
Middle Name:ANCA
Last Name:VLASE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:197 MORICHES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2169
Mailing Address - Country:US
Mailing Address - Phone:631-584-2089
Mailing Address - Fax:
Practice Address - Street 1:1 PELLEGRINO DRIVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-9440
Practice Address - Country:US
Practice Address - Phone:631-444-6412
Practice Address - Fax:631-444-9536
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-21
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY007828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant