Provider Demographics
NPI:1962496356
Name:VARGAS ROLDAN, YEZENIA IVETTE (MPT)
Entity Type:Individual
Prefix:MS
First Name:YEZENIA
Middle Name:IVETTE
Last Name:VARGAS ROLDAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:SAN SEBASTIAN
Mailing Address - State:PR
Mailing Address - Zip Code:00685-1667
Mailing Address - Country:US
Mailing Address - Phone:787-896-4080
Mailing Address - Fax:
Practice Address - Street 1:19 CALLE ANDRES MENDEZ LICIAGA
Practice Address - Street 2:PADUA BUILDING
Practice Address - City:SAN SEBASTIAN
Practice Address - State:PR
Practice Address - Zip Code:00685-2222
Practice Address - Country:US
Practice Address - Phone:787-896-4080
Practice Address - Fax:787-896-4080
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1215225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P28479Medicare UPIN
20524Medicare ID - Type Unspecified