Provider Demographics
NPI:1073672929
Name:VASSA, PAUL M (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:M
Last Name:VASSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HILL ST
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1807
Mailing Address - Country:US
Mailing Address - Phone:516-983-3725
Mailing Address - Fax:
Practice Address - Street 1:233 UNION AVE
Practice Address - Street 2:STE 102
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-1813
Practice Address - Country:US
Practice Address - Phone:631-664-6841
Practice Address - Fax:631-368-4172
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU86972Medicare UPIN
NYX7E121Medicare ID - Type Unspecified