Healthcare Provider Details

I. General information

NPI: 1326270158
Provider Name (Legal Business Name): VICTORIA GRACE ACQUESTA RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 SOUTH AVE SUITE 306
STATEN ISLAND NY
10314-3403
US

IV. Provider business mailing address

1110 SOUTH AVE SUITE 306
STATEN ISLAND NY
10314-3403
US

V. Phone/Fax

Practice location:
  • Phone: 718-761-4700
  • Fax: 718-494-2767
Mailing address:
  • Phone: 718-761-4700
  • Fax: 718-494-2767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013216
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: