Provider Demographics
NPI:1144789538
Name:ACEVEDO, VIVIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S HEATH TER
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4075
Mailing Address - Country:US
Mailing Address - Phone:714-745-7609
Mailing Address - Fax:
Practice Address - Street 1:8101 NEWMAN AVE STE D
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-7042
Practice Address - Country:US
Practice Address - Phone:714-545-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56571363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant