Provider Demographics
NPI:1689662801
Name:VENGHIATTIS, VALERIE (PA)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:VENGHIATTIS
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2081 BRONZE STAR DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5423
Practice Address - Country:US
Practice Address - Phone:530-668-2600
Practice Address - Fax:530-661-1081
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1386363LF0000X
CA20116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MV1256658OtherDEA
CO83673725Medicaid
C418228Medicare PIN
CO83673725Medicaid