Provider Demographics
NPI:1598452245
Name:VERGARA, ADAM BRYAN
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:BRYAN
Last Name:VERGARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22105 LUKENS LN
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-1513
Mailing Address - Country:US
Mailing Address - Phone:951-966-2359
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1819
Practice Address - Country:US
Practice Address - Phone:909-580-6343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty