Provider Demographics
NPI:1962484675
Name:VIGEANT, DAVID P (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:P
Last Name:VIGEANT
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 1:77 W BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1040
Mailing Address - Country:US
Mailing Address - Phone:315-535-9202
Mailing Address - Fax:315-535-9207
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:ANTWERP
Practice Address - State:NY
Practice Address - Zip Code:13608-4164
Practice Address - Country:US
Practice Address - Phone:315-659-8993
Practice Address - Fax:315-659-2418
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004813OtherLICENSE