Provider Demographics
NPI:1386198083
Name:VITAL, NINA C (PA-C)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:C
Last Name:VITAL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 SPRUCE STREET
Mailing Address - Street 2:4 SILVERSTEIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2096
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:4 SILVERTSTEIN
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-662-2096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant