MEDICARE: MR. ROLAND VASADZE RN

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	163W00000X	Registered Nurse	614483	NY
2	163WP2201X	Ambulatory Care Registered Nurse	614483	NY

General Provider Information

NPI Number	:	1891027942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROLAND VASADZE RN

Provider Business Mailing Address
First Line	:	1958 50TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1364
Country	:	US
Telephone Number	:	718-877-7384
Fax Number	:

Provider Business Practice Location Address
First Line	:	1958 50TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-1364
Country	:	US
Telephone Number	:	718-877-7384
Fax Number	:

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

Provider Enumeration Date	:	01/31/2010
Last Update Date	:	01/31/2010

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