Provider Demographics
NPI:1114173978
Name:RODRIGUEZ, VANESSA M (PA)
Entity Type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:M
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 E 86TH CT
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6259
Mailing Address - Country:US
Mailing Address - Phone:219-769-9070
Mailing Address - Fax:219-769-1758
Practice Address - Street 1:205 E 86TH CT
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6259
Practice Address - Country:US
Practice Address - Phone:219-769-9070
Practice Address - Fax:219-769-1758
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001486A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100212430Medicaid