Provider Demographics
NPI:1639702905
Name:VARDANYAN, MELIKSET (NP)
Entity Type:Individual
Prefix:
First Name:MELIKSET
Middle Name:
Last Name:VARDANYAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 OCEAN PKWY APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-5066
Mailing Address - Country:US
Mailing Address - Phone:917-254-7520
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST STE 306
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:844-403-4325
Practice Address - Fax:424-625-0010
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily