Provider Demographics
NPI:1477279578
Name:RODRIGUEZ VEGA, FERNANDO (NP)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:RODRIGUEZ VEGA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 RAVENNA AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1327
Mailing Address - Country:US
Mailing Address - Phone:310-469-3753
Mailing Address - Fax:
Practice Address - Street 1:1716 RAVENNA AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-1327
Practice Address - Country:US
Practice Address - Phone:310-469-3753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95021310363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health