Healthcare Provider Details

I. General information

NPI: 1750743894
Provider Name (Legal Business Name): DYLAN ROBERT VENDRYES P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

20 WASHINGTON SQ
WORCESTER MA
01604-4013
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-5000
  • Fax:
Mailing address:
  • Phone: 508-363-5373
  • Fax: 508-363-7157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA5640
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA5640
License Number StateMA

VII. Legacy identifiers

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

# 1
IdentifierPA5640
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerDPH LICENSE NUMBER
# 2
Identifier1442973
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerDPH CONTROL NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: