Provider Demographics
NPI:1417440603
Name:CASERIO, VINCENT MARTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:MARTIN
Last Name:CASERIO
Suffix:
Gender:M
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 1:2550 W MAIN ST STE 301
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7003
Mailing Address - Country:US
Mailing Address - Phone:626-457-6900
Mailing Address - Fax:626-457-5022
Practice Address - Street 1:11550 INDIAN HILLS RD STE 261
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1244
Practice Address - Country:US
Practice Address - Phone:818-361-0917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
CAPA5670363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA55670OtherSTATE LICENSE
1152011OtherNCCPA