MEDICARE: THERESA VERGARA AGACNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	431517	NY

General Provider Information

NPI Number	:	1144870056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA VERGARA AGACNP-BC

Provider Business Mailing Address
First Line	:	4428 PURVES ST APT 27B
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3086
Country	:	US
Telephone Number	:	646-498-3829
Fax Number	:

Provider Business Practice Location Address
First Line	:	4428 PURVES ST APT 27B
Second Line	:
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3086
Country	:	US
Telephone Number	:	402-880-4474
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2019
Last Update Date	:	06/09/2022

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