Provider Demographics
NPI:1225197668
Name:VASQUEZ-BYNUM, VERONICA TERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:VERONICA
Middle Name:TERESA
Last Name:VASQUEZ-BYNUM
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:P.O. BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1421
Practice Address - Street 1:8960 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 204
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9633
Practice Address - Fax:239-343-9635
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105013363A00000X
TXPA03122363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001540600Medicaid
TXP57521Medicare UPIN
FLCQ139ZMedicare PIN
TXP57521Medicare UPIN