Healthcare Provider Details

I. General information

NPI: 1699193318
Provider Name (Legal Business Name): AMY ELIZABETH VAGEDES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

1195 HASELTON RD.
CLEVELAND OH
44121
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-6455
  • Fax:
Mailing address:
  • Phone: 330-575-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number34.012353
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: