Provider Demographics
NPI:1538213368
Name:VONHAGN, RICHARD L (NP)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:L
Last Name:VONHAGN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 W WATER ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-2435
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2099
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1629
Practice Address - Country:US
Practice Address - Phone:607-735-4623
Practice Address - Fax:607-737-4530
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF333853363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02553400Medicaid
NYJ400067074Medicare PIN
NY02553400Medicaid