Provider Demographics
NPI:1609386028
Name:CARMONA, VANESSA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:ELIZABETH
Last Name:CARMONA
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 1:5347 KINGSBURY PL NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-2195
Mailing Address - Country:US
Mailing Address - Phone:203-909-8832
Mailing Address - Fax:
Practice Address - Street 1:20 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:MN
Practice Address - Zip Code:55964-1497
Practice Address - Country:US
Practice Address - Phone:507-534-3885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12481363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant