Healthcare Provider Details

I. General information

NPI: 1063418457
Provider Name (Legal Business Name): THOMAS VENDITTI RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3768 ST HWY 30
BROADALBIN NY
12025
US

IV. Provider business mailing address

PO BOX 923
BROADALBIN NY
12025-0923
US

V. Phone/Fax

Practice location:
  • Phone: 518-883-3121
  • Fax: 518-883-3280
Mailing address:
  • Phone: 518-883-3121
  • Fax: 518-883-3280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005837
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: