Healthcare Provider Details

I. General information

NPI: 1588592760
Provider Name (Legal Business Name): NICHOLAS MICHAEL VEGA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 LAMBERTS LN
STATEN ISLAND NY
10314-7210
US

IV. Provider business mailing address

27 PARK DR N
STATEN ISLAND NY
10314-5701
US

V. Phone/Fax

Practice location:
  • Phone: 718-370-0422
  • Fax: 718-983-6152
Mailing address:
  • Phone: 929-202-1428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: