Provider Demographics
NPI:1649812512
Name:LANTIGUA, VILMA
Entity type:Individual
Prefix:
First Name:VILMA
Middle Name:
Last Name:LANTIGUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2417
Mailing Address - Country:US
Mailing Address - Phone:718-589-2440
Mailing Address - Fax:
Practice Address - Street 1:1065 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2417
Practice Address - Country:US
Practice Address - Phone:718-589-2440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026125363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program