Provider Demographics
NPI:1275643470
Name:VITALE, STEPHEN DAVID (PA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DAVID
Last Name:VITALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BUCKINGHAM PL
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-1835
Mailing Address - Country:US
Mailing Address - Phone:516-599-4475
Mailing Address - Fax:516-599-2185
Practice Address - Street 1:11110 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-2322
Practice Address - Country:US
Practice Address - Phone:718-847-2688
Practice Address - Fax:718-847-2627
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006447363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS79811Medicare UPIN