Provider Demographics
NPI:1659692473
Name:VEGA, VANESSA LAURA (PA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LAURA
Last Name:VEGA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:562-499-6171
Practice Address - Street 1:7400 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-3011
Practice Address - Country:US
Practice Address - Phone:916-722-2227
Practice Address - Fax:916-723-0142
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20856363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA20856Medicaid
CAPA20856 - EFF 6/4/12OtherMEDI-CAL
CAEH482YMedicare PIN
CAEH482UMedicare PIN
CAEH482TMedicare PIN
CAPA20856Medicaid
CAPA20856 - EFF 6/4/12OtherMEDI-CAL
CAEH482XMedicare PIN