Provider Demographics
NPI:1083482343
Name:VEGA, MANUEL (NP)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:VEGA
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 1:1205 W DUNBAR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-7033
Mailing Address - Country:US
Mailing Address - Phone:602-931-7741
Mailing Address - Fax:
Practice Address - Street 1:1205 W DUNBAR DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-7033
Practice Address - Country:US
Practice Address - Phone:602-931-7741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ301105363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily