Provider Demographics
NPI:1386252724
Name:PAGAN, VINCENT P
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:P
Last Name:PAGAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 LAKE AVE S
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1853
Mailing Address - Country:US
Mailing Address - Phone:631-291-5083
Mailing Address - Fax:
Practice Address - Street 1:271 LAKE AVE S
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1853
Practice Address - Country:US
Practice Address - Phone:631-291-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-22
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031792225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist