Provider Demographics
NPI:1023337433
Name:VEGA, JONATHAN ANDREW (LPN)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:VEGA
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 E WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-3855
Mailing Address - Country:US
Mailing Address - Phone:631-348-1816
Mailing Address - Fax:
Practice Address - Street 1:27 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-3855
Practice Address - Country:US
Practice Address - Phone:631-560-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300658164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse