Provider Demographics
NPI:1851648687
Name:VALLEJO, VICTORIA CATHERINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:CATHERINE
Last Name:VALLEJO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:CATHERIN
Other - Last Name:GLOWACKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11 MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-2242
Mailing Address - Country:US
Mailing Address - Phone:732-663-0300
Mailing Address - Fax:732-663-0301
Practice Address - Street 1:11 MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-2242
Practice Address - Country:US
Practice Address - Phone:732-663-0300
Practice Address - Fax:732-663-0301
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015871363A00000X
NJ25MP00464400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY015871OtherSTATE LICENSE
NJ25MP00464400OtherSTATE LICENSE