Provider Demographics
NPI:1639236300
Name:VIGIL, CARLOS A (PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:VIGIL
Suffix:
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 1:209 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4265
Mailing Address - Country:US
Mailing Address - Phone:253-596-3300
Mailing Address - Fax:
Practice Address - Street 1:209 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4265
Practice Address - Country:US
Practice Address - Phone:253-596-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003501363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8343337Medicaid
WAG000245414Medicare PIN
WAGAB16548Medicare PIN
WAGAB16550Medicare PIN
WAS87947Medicare UPIN
WAGAB16549Medicare PIN
WAGAB16547Medicare PIN
WA8343337Medicaid
WAGAB16546Medicare PIN