Healthcare Provider Details

I. General information

NPI: 1598222168
Provider Name (Legal Business Name): MICHAEL ANDREW VROLYK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2019
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 SECOND AVE
WALTHAM MA
02451-1127
US

IV. Provider business mailing address

52 SECOND AVE BLDG 52
WALTHAM MA
02451-1127
US

V. Phone/Fax

Practice location:
  • Phone: 177-249-3386
  • Fax:
Mailing address:
  • Phone: 617-724-9338
  • Fax: 781-487-4003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA6899
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: