Provider Demographics
NPI:1588211288
Name:VELA, THERESA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:VELA
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 1:4199 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-1733
Mailing Address - Country:US
Mailing Address - Phone:617-323-4440
Mailing Address - Fax:
Practice Address - Street 1:4199 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-323-4440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2020-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA7192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant