Provider Demographics
NPI:1093576969
Name:VETTATH, SURYA
Entity Type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:VETTATH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-4043
Mailing Address - Country:US
Mailing Address - Phone:845-893-5104
Mailing Address - Fax:
Practice Address - Street 1:7 ARCADIAN DR
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-1121
Practice Address - Country:US
Practice Address - Phone:845-893-5104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF352488363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily