Provider Demographics
NPI:1235475005
Name:AGUIRRE, BLOSSOM DAWN VENCER (MS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:BLOSSOM DAWN
Middle Name:VENCER
Last Name:AGUIRRE
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 3RD STREET PROMENADE STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1382
Mailing Address - Country:US
Mailing Address - Phone:800-567-5544
Mailing Address - Fax:
Practice Address - Street 1:1316 3RD STREET PROMENADE STE 201
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1382
Practice Address - Country:US
Practice Address - Phone:800-567-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-21
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22589363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant