Provider Demographics
NPI:1255473724
Name:DE LA VEGA, MARIA TERESA (NP)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:TERESA
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9 MINER ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1208
Mailing Address - Country:US
Mailing Address - Phone:315-386-8821
Mailing Address - Fax:315-386-4732
Practice Address - Street 1:9 MINER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1208
Practice Address - Country:US
Practice Address - Phone:315-386-8821
Practice Address - Fax:315-386-4732
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF300013-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00583697Medicaid
NYMD135771OtherDEA