Provider Demographics
NPI:1689909046
Name:VARGAS, EDGAR ERNESTO (PA)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ERNESTO
Last Name:VARGAS
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 1:11666 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3606
Mailing Address - Country:US
Mailing Address - Phone:707-322-4980
Mailing Address - Fax:
Practice Address - Street 1:11666 CEDAR ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3606
Practice Address - Country:US
Practice Address - Phone:707-322-4980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant