Provider Demographics
NPI:1053112680
Name:VANEGAS, MARTIN STEVENSON (PA)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:STEVENSON
Last Name:VANEGAS
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94-20 GUY BREWER BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11451-0001
Mailing Address - Country:US
Mailing Address - Phone:718-262-2000
Mailing Address - Fax:
Practice Address - Street 1:94-20 GUY BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11451-0001
Practice Address - Country:US
Practice Address - Phone:718-262-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03350601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant