Healthcare Provider Details

I. General information

NPI: 1265100069
Provider Name (Legal Business Name): VAG SPECIALIST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 SE OSCEOLA ST STE 200A
STUART FL
34994-2503
US

IV. Provider business mailing address

401 SE OSCEOLA ST STE 200A
STUART FL
34994-2503
US

V. Phone/Fax

Practice location:
  • Phone: 561-318-0252
  • Fax: 561-744-0735
Mailing address:
  • Phone: 561-318-0252
  • Fax: 561-744-0735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA NIETO
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 412-398-5059