Provider Demographics
NPI:1588670442
Name:VEGA, EDGARDO ANIBAL SR (PA)
Entity Type:Individual
Prefix:
First Name:EDGARDO
Middle Name:ANIBAL
Last Name:VEGA
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9730 SAVANNAH ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6989
Mailing Address - Country:US
Mailing Address - Phone:561-352-5245
Mailing Address - Fax:
Practice Address - Street 1:1037 S STATE ROAD 7
Practice Address - Street 2:SUITE 211
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6138
Practice Address - Country:US
Practice Address - Phone:561-798-3030
Practice Address - Fax:561-798-8242
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P75567Medicare UPIN
DA4102118Medicare ID - Type Unspecified