Healthcare Provider Details

I. General information

NPI: 1215579685
Provider Name (Legal Business Name): NICHOLAS VETOLLIS RUGGIERI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28037 BOX PSC
APO AE
09112-8037
US

IV. Provider business mailing address

PSC 411 BOX 6575
APO AE
09112-0066
US

V. Phone/Fax

Practice location:
  • Phone: 423-972-1488
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: