Provider Demographics
NPI:1386750297
Name:VITAL PA PLLC
Entity type:Organization
Organization Name:VITAL PA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTO
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:CONCEPCION
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:917-517-5733
Mailing Address - Street 1:35-20 LEVERICH STREET
Mailing Address - Street 2:STE 230B
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-3973
Mailing Address - Country:US
Mailing Address - Phone:917-517-5733
Mailing Address - Fax:718-343-1157
Practice Address - Street 1:35-20 LEVERICH STREET
Practice Address - Street 2:STE 230B
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-3973
Practice Address - Country:US
Practice Address - Phone:917-517-5733
Practice Address - Fax:718-343-1157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2009-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty