Provider Demographics
NPI:1538779442
Name:VARGAS, ANTONIO TRAVIS (CNP)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:TRAVIS
Last Name:VARGAS
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932909
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0026
Mailing Address - Country:US
Mailing Address - Phone:330-854-4281
Mailing Address - Fax:330-854-0829
Practice Address - Street 1:1302 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:OH
Practice Address - Zip Code:44641-1114
Practice Address - Country:US
Practice Address - Phone:330-875-5544
Practice Address - Fax:330-875-8150
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0027284363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology